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LETTER 



HON. ISAAC PARKER, 

CHIEF JUSTICE OF THE SUPREME COURT OF THE STATE OF 
MASSACHUSETTS, 

CONTAINING REMARKS 



DISLOCATION OF THE HIP JOINT, 

OCCASIONED 

BY THE PUBLICATION OF A TRIAL 

WHICH 

TOOK PLACE AT MACHIAS, IN THE STATE OF MAINE, JUNE, 1824. 



BY JOHN C. WARREN, M. D. 

PROFESSOR OF ANATOMY AND SURGERY IN HARVARD UNIVERSITY, AND ACTING 
SURGEON IN THE MASSACHUSETTS GENERAL HOSPITAL. 



WITH AN APPENDIX 

OF 
DOCUMENTS FROM THE TRIAL NECESSARY TO ILLUSTRATE 

THE 

HISTORY OF THE CASE. 






CAMBRIDGE ; 
PRINTED BY HILLIARD AND METCALF. 

1826. 



•Viz- 



TO THE 

HONOURABLE CHIEF JUSTICE PARKER. 

Dear Sir, 

It may be thought strange, by some persons, that 
I should address to you a pamphlet on a subject ap- 
pertaining to the medical profession. This liberty I 
have been led to take, partly from having intimated 
to you in conversation, that my opinion had been 
misrepresented in the publication which has drawn 
forth these sheets ; and partly, from having consid- 
ered this topic to be connected with jurisprudence, 
as well as medicine : but principally, that I might 
add respectability to these remarks by the sanction 
of a name, high in official station, and still higher in 
public confidence and respect. 

The circumstances which involved me in this trial, 
and compelled me to make this publication, were 
briefly these. An individual, who had met with a 
grievous injury, applied to me for professional aid. 
This was administered to him to the utmost of my 
ability. He went away, and I considered my con- 
cern in the case to be closed. Much to my surprise, 
and I may say, dissatisfaction, after the lapse of a 
considerable time, I was summoned, in a legal 
way, to give a deposition to the facts of this case, 
within my cognizance. Being thus compelled, I gave 



IV 



the deposition, to the best of my memory, and 
with the most impartial disposition as to the parties. 
At the distance of two or three years, more or less, 
for I do not remember exactly, it came to my know- 
ledge, that this same deposition had been made use 
of in a court of justice ; that having been thought 
to operate unfavourably on one of the parties, it was 
criticised by the attorney for that party, and a very 
great error discovered therein ; and that the said 
attorney had commented on my opinion and practice 
in very severe and overpowering terms. My colleague 
physicians in the Massachusetts General Hospital, 
though less concerned in the business, were, I was 
told, also attacked, and made the objects of sharp re- 
marks. Even public institutions, it was said, from the 
unfortunate circumstance of my connexion with them, 
had not altogether escaped the tirade of the said at- 
torney. A great triumph, I learnt, had been thought 
to be obtained ; and as the sphere of a court of justice 
was thought too limited for enjoying it, an account 
of the whole affair would soon be given in print, by 
the ingenious attorney, and would be distributed 
widely through the country, to the great confusion 
and serious detriment of my unfortunate, mistaken 
self and colleagues. 

Not long after, I saw and read the publication. 
Though formidable at first view, a very little exami- 
nation was sufficient to satisfy me, that it was one 
of those things, which might be safely trusted to the 
salutary reaction of public opinion ; and that I had 
nothing to do, but to lay it aside and forget it, which 
I accordingly did. 



At a subsequent period 1 was informed, that the 
confident tone of the adverse plea in this case had 
really imposed on many persons, not well acquainted 
with the subject ; that my silence on an affair of 
so much eclat, had been construed into an admission 
of the charges against me ; and that if I really had 
any thing to say in my own defence, it was proper 
to say it, for the sake at least of my colleagues, and 
that of public institutions, even if I was indifferent 
to my own reputation. 

Such being the opinion of estimable persons, I 
determined to attend to the business, as soon as I 
could find a convenient opportunity ; and if, on due 
investigation, it should appear that I could by any 
means poise the weighty arguments of the attorney, 
and muster facts able to stand up before those arrayed 
against me, to do it with the least possible delay. 
Since then, I have waited for the convenient time ; 
but finding that unhappily it did not arrive, it became 
imperious on me to take the field, under all disad- 
vantages, and to make the most of the resources 
ready at hand. 

There are people, perhaps, who may think it hard, 
that the fact of my having been engaged in perform- 
ing an official duty, should expose me to be the mark 
and butt of a witty attorney, first in a court of justice, 
and then in print. To this complaint it would no 
doubt be answered, that the cause of public justice 
required such an exhibition, and that a good citizen 
should submit to these sacrifices of feeling, without 
a murmur. Whether, if such answer were made, it 
would be thought a true and honest one, I submit to 



VI 



the decision of the public ; and especially to that 
most able portion of it, the profession of the law. 
They can best tell, whether right and justice are 
helped by declamatory harangues respecting private 
character ; and whether, when these have been de- 
livered to full effect, in the court of justice, it is 
necessary, judicious, and worthy to be a precedent, 
to put them in print, and distribute them through 
the country for general information. If such a course 
is considered justifiable, it surely becomes me to w r arn 
my own fraternity to be careful of giving depositions 
for legal purposes. For there is, perhaps, no one 
secure against the hazard of being made a subject 
of similar attack, and its necessary consequences, the 
loss of time and relinquishment of duties : and to 
whomever it may so happen, he must even be will- 
ing to think himself fortunate, if he should have the 
lot to fall into the hands of an equally ingenious, 
witty, and well-bred attorney, who, while he deli- 
cately cuts off part of his reputation, is willing to 
allow him the remainder. 

The publication of this trial, however, may not be 
without its advantages ; for, as in the course of the 
discussion I have been compelled to state the princi- 
ples on which dislocations are produced and cured, 
it may thence happen that some gentlemen, reading 
this as a controversial pamphlet, which perhaps they 
would have passed over, had it been a formal disser- 
tation, may come to the opinion that dislocations are 
to be known and treated by fixed rules, formed on 
scientific bases, and not to be considered the sub- 
jects of a practice altogether empirical or inheritable 
by nature. 



vu 



In settling the course best to be pursued, in an 
affair made difficult by the number and acuteness of 
my antagonists, the decision of one point has given me 
much concern. The opinions of medical practitioners, 
some of them very respectable, were brought forward 
in opposition to mine, long after mine had been known ; 
a part of these, indeed, for the most manifest purpose 
of overturning the notions I had ventured to form. 
It was indispensable for me to meet these contradict- 
ing opinions, to examine their strength, and to show, 
if I could, their weakness. In doing this in print, 1 
perceived there was danger of coming in contact with 
the feelings of the parties concerned, and throwing 
on them some degree of the inconveniences to which 
I had been exposed. This is what I seriously wished 
to avoid. I wish to wound no man, however culpable ; 
and especially I desire not to couple the name of any 
one, in a permanent bond, with the imputation of error. 
This evil has, I trust, been avoided by the omission 
of all names, to which I was obliged to fix terms 
different from those of commendation. Offensive 
epithets, indeed, I have sought to avoid wholly ; 
and if in any case I have failed, it will be a subject 
of greater regret to me, than to any other person. 

The defects of style, the want of logical arrange- 
ment, and the interminable use of the first person 
singular, require, I am well satisfied, a great many 
excuses ; and I am well aware, that none such are 
ever tolerated. For the last, perhaps, I ought to offer 
the necessity of the case ; but as to the former, I 
can only plead, in abatement of censure, the very 
irregular, unsettled nature of the profession I have 



vm 



the honour to cultivate ; and the serious obstacles 
it presents to pursuing a continuous train of thought. 
All know that the high responsibilities of this pro- 
fession demand a great quantity and a great variety 
of personal experience ; a great knowledge of the 
opinions and experience in books, and a thoughtful 
application of the whole to the new cases of each 
day : but there are few people who know, or at least 
who realize, how little the medical practitioner of 
this country can command his time and thoughts, 
and how freely these are at the disposal of every 
body besides himself. Such considerations will, I 
am sensible, form an imperfect excuse for defects 
of style in this pamphlet ; but happily, style, force of 
epithets, and even logical arrangement, are compara- 
tively not important ; my main business is with 

FACTS. 

Boston, July 4, 1826. 



LETTER. 



Some time in the month of December, 1821, I was 
called to visit a stranger at a public house in Boston. 
He informed me that he had received a severe injury in 
the hip, and had travelled a considerable distance for 
the purpose of obtaining surgical aid. His account of 
his misfortune was as follows : He was riding a spirited 
horse, when the animal, being restiff, suddenly reared, 
and fell backward on his rider. The weight of the 
horse was received on the inside of the left thigh, the 
patient having fallen on his back, a little inclined, as he 
said, to the left side. When he attempted to rise, he 
found himself crippled, and had continued so from that 
time. 

I proceeded to examine the nature of this injury. 
For this purpose, the patient was stripped, and placed 
in different situations. First, I examined him in the 
upright posture, — afterwards sitting, and then lying on 
a bed. I made various movements of the disordered 
limb, and compared it with the sound one. Having 
continued this investigation as long as my time permit- 
ted, 1 told the patient, Mr. Lowell, that his case ap- 
peared to be peculiar and difficult ; that 1 must examine 
him again, and in the meanwhile should consider the 
appearances. He readily assented, and it was agreed 
that I should see him the next day. As the case was 
uncommon, I felt myself bound to consult the best au- 
thority on the subject. For this purpose, I referred to the 
late work of Sir Astley Cooper on dislocations, and with 
1 



2 

the additional light thus obtained, proceeded the next 
day to another investigation of the case. The patient 
was again examined with care and attention. The re- 
sult was a conviction that the limb was dislocated. The 
appearances were such as I thought could not be attrib- 
uted to any other kind of derangement. The two most 
remarkable of these, omitting others at present, were, 
that the thigh was bent forward, so as to form a con- 
siderable angle with the body ; and, at the same time, 
the limb was longer than the other by about three inch- 
es ; that is, the knee of the injured side extended about 
this length, lower than the other. Such an appearance 
as the last named, it was clear, could only be caused 
by a displacement of the head of the thigh bone, or a 
very extensive fracture of the bones of the pelvis. As 
the other distinguishing symptoms of the latter accident 
did not exist, it followed, that the deformity must arise 
from the former. The determination of the direction 
taken by the head of the bone when it was thrown out, 
or the kind of dislocation was not so easily settled. As 
the limb was lengthened, it was clear that the present 
situation of the head of the bone could be neither above, 
nor on a level with, but below that of its natural socket ; 
or that the dislocation must be downwards. There be- 
ing two courses which the head of the thigh bone could 
take in a downward direction, either forward or back- 
ward, I had next to consider with which of these two 
accidents the phenomena would best coincide. If the 
dislocation were forwards, I might expect to find the 
round head of the thigh bone in front of the socket, and 
near the upper part of the thigh ; the limb being at the 
same time much turned out ; on the other hand, if the 
dislocation were backwards, the head of the bone would 
be found behind and below the socket, and the knee of 
the patient, according to Sir Astley Cooper, a$ I 
thought, and also according to some other authors, turn- 
ed in towards the other. The existence of the former 
of these signs, of the dislocation backwards, and 
the most striking and characteristic one. I ascertained to 



my satisfaction ; but the situation of the limb did not 
accord with the representation given of its necessary 
direction in such a case. What decision could I come 
to in this state of the contradictory phenomena ? On the 
one side, there appeared to be the opinion of a high au- 
thority ; on the other, that of my own senses. When I 
further considered the matter, it became obvious that the 
symptoms mentioned by Sir Astley Cooper referred to a 
different accident ; to a lodgment of the head of the bone 
higher up ; and that if a lodgment of the bone should 
take place on the parts below the level of the socket, 
the movements of the limb would not be confined to the 
same degree, as in the other instance, nor would it 
have the same direction. Having duly considered 
this, and not being able to find the head of the bone 
in front of the articulating cavity ; but on the con- 
trary, being satisfied of its existence behind it, I con- 
cluded that the dislocation was backwards, as well as 
downwards. The more full and continued display of 
the disordered part, and of its movements during the 
subsequent attempts to reduce the bone, by giving addi- 
tional means of examination, confirmed me in this opin- 
ion. Such, or nearly such, w r as the course of my obser- 
vations and reasonings, at the time when the injury was 
presented for my opinion. 

Having formed a judgment of the nature of the de- 
rangement I told the patient, that I was sorry to be 
obliged to say, that he had a dislocation of the hip joint 
of the most difficult kind. This information did not 
seem, as I had expected it would, to surprise him ; for 
having heard my opinion, he proceeded to state, that he 
had in the beginning, supposed the limb to be put out ; 
that he had applied to surgical practitioners in his vicin- 
ity, and had been operated on for a dislocated hip ; that 
the bone was supposed to have been restored to its 
place ; and that he himself thought so, till he got up 
and began to try his limb, when he found it in a crip- 
pled state, and was after a time led to believe, that it 
had never been reduced to its proper situation. He did 



not, as well as I can remember, name the practitioners 
to whom he had applied, nor did I hear their names till 
a long time after, nor know their situations till I saw 
the published trial. 

A conversation then took place between Mr. Lowell 
and myself, which was much as follows. " Since my 
limb, as you tell me, is out of place, what is to be done 
to restore it?" 1 answered, "Nothing." " Cannot 
you restore the use of my limb ?" " No." " Are not 
limbs sometimes set after they have been out of joint as 
long as mine ?" " Sometimes ; instances of the shoul- 
der being set, after having been dislocated a number of 
months, have occurred, but I never knew a thigh-bone 
restored, after it had been dislocated so long as yours." 
V Are you not willing to make an attempt to get the 
bone into its socket ? Must I remain a cripple for life ?" 
" Dislocations of the thigh bone are usually difficult to 
reduce, even when they are recent. Yours is the most 
difficult of four kinds of dislocation ; considering this 
fact, and the time elapsed since its occurrence, there 
is no probability that your limb can be restored ; not- 
withstanding, if you wish a trial to be made, and are 
prepared to submit to the suffering connected with it, I 
am ready to make it in the best manner I can for you." 
;i Would it put my life in danger?" " I think not ; I 
should not feel warranted in carrying any measures so 
far as to expose your life." " Well, I am willing to 
suffer any thing to get the use of my limb. I am young, 
and depend on my bodily exertions for my living. [ 
am ready to run some risk of my life, for the chance of 
getting the use of my limbs again." 

As we could not expect to find in a public coffee- 
house, the accommodations and apparatus necessary for 
our purpose, I advised Mr. Lowell to go to the Massa- 
chusetts General Hospital, where every thing requisite 
would be amply supplied. In order that he and I might 
have the full advantage of the surgical skill of the place, 
I requested a meeting of the consulting physicians of 
the Hospital. Four, out of six, of these gentlemen at- 



tended — Drs. Townsend, Mann, Welsh, and Spoon- 
er. To these gentlemen I stated in a very general 
manner, that the patient appeared to have a dislocation 
of the hip, which had existed some time ; that he was 
desirous to have an attempt made to reduce it, although 
I had discouraged it. I then proposed that they should 
examine it themselves, and give their opinion of the na- 
ture of the accident, and of the expedience of an at- 
tempt to restore the limb to its place. The patient was 
according subjected to their examination. They con- 
ducted it in their own way, and continued it, I presume, 
till they were satisfied ; but what was their mode of 
examination, and what the time taken for making it, is 
wholly out of my recollection. This however is cer- 
tain, that they came to a decided conclusion, that Mr. 
Lowell's limb was displaced ; and as to its restoration, 
they were equally well satisfied that it was highly im- 
probable, if not impossible. They thought, however, 
that if the patient well understood, that its reduction 
could not, upon any common and reasonable principle, 
be expected, and that he would experience much pain 
in the attempt, and that if, with this knowledge, he still 
continued to desire the operation, it would be expedient 
to perform it. The ground on which this conclusion 
was placed, was not the wish of the patient merely ; but 
it was founded on the conviction, that he must be maim- 
ed for life, if left in the state in which he then was ; on 
the consideration, that though the successful result of 
an attempt at reduction was highly improbable, it could 
not be considered as an absolute and physical impossi- 
bility ; and on the maxim, that a doubtful remedy in a 
desperate case is better than none. I desired the gentle- 
men to converse with the patient, to state to him their 
opinion, and hear what he had to say. This they did ; 
and, as I was absent during a great part of the time oc- 
cupied by this conversation, I cannot say what passed ; 
but after I rejoined them, I heard them use language 
not calculated to induce him to submit to an operation ; 
and I heard him repeat to them, very much the same 



(j 

words he had before used to me. Such being the re- 
sult of this conversation, and such the resolution of the 
patient, I felt encouraged to employ my best exertions 
for his relief, from his present unfortunate condition. 

Arrangements were therefore made, to prepare him 
for the operation, according to the practice founded on 
the doctrines of the great master of his art, the sagacious 
John Hunter ; which have been so ably displayed by 
his pupils, especially the distinguished Sir Astley 
Cooper. 

" In attempting," says Mr. Hunter, " the reduction 
of a dislocated bone, the indications are, 

" 1. To make the naturally most immoveable part a 
fixed point. 

" 2. To overcome the action of the muscles, which 
draw up the dislocated bone, and resist its recovering- 
its natural situation. 

" 5. Then by making lateral pressure, to force the 
head of the dislocated bone into its place. 

" Here then a retrograde motion is to be observed, 
and the last action in the dislocation is the first to be 
overcome ; the last action is that of the muscles draw- 
ing up the dislocated bone, and their force being over- 
come by distension in a proper direction, and by it, the 
head of the bone being brought to the edge of its re- 
ceiving articular surface, is then by lateral pressure to 
be forced into its place. 

" If a dislocated bone remain in its unnatural state a 
considerable time, and in contact with a bony surface, 
by degrees it forms a new socket for itself ; the bone 
against which it presses undergoes absorption, and the 
adhesive inflammation arising in the parts around, a 
new joint is formed. These may be called necessitous 
joints. 

" This happens commonly in irreducible dislocations 
of the thigh bone." 

The principles roughly sketched by John Hunter, 
have been more distinctly displayed by Sir Astley 
Cooper. While Mr. Hunter taught that the principal 



resistance to reduction was caused by muscular action, 
Sir Astley Cooper has .told us how to overcome this 
resistance. Instead of attacking the resisting powers 
by mere mechanical force, he goes at once to the source 
of these powers, and cuts it ofT. The means he sug- 
gests for effecting this object, are all those agents known 
to weaken the muscles. Of which, bleeding, the warm 
bath, and nauseating medicines are among the most 
efficient. 

Guided principally by such authorities, I proceeded 
to make the arrangements for the proposed trial. The 
patient was about 30 years of age, I presume, and rath- 
er muscular ; but having been recently confined by his 
accident, the muscles were not rigid. In the morning, 
he was subjected to the action of a powerful purgative. 
The warm bath being afterwards prepared, he was im- 
mersed therein, at as high a temperature as he could bear, 
and retained there for an hour. Small doses of tartar- 
emetic were given, in the way suggested by Sir Astley 
Cooper, so as to produce that deadly sickness, which re- 
laxes the whole muscular system : finally, at the moment 
the apparatus was to be applied, a vein was opened in the 
arm, and blood drawn as rapidly, and in as large quan- 
tities, as the faintness of the patient permitted. 

The apparatus having been previously prepared, he 
was placed on a table covered with blankets, on his 
right side, and carefully fixed to the table by bands 
passed round the pelvis. Other bands were passed 
between the thighs, and secured to the wall of the a- 
partment. Thus the pelvis, being immoveable in the 
transverse and in the longitudinal directions, was made 
the " fixed point," on which to operate. The powers 
designed to extend the limb were then applied in the 
two directions opposite to those of the forces meant to 
keep the body steady. Soft substances were placed 
around the middle of the thigh, and about them a strong 
band, to which were attached the dislocation pullies, in 
such a manner as to draw at right angles to the body ; 
while other cords were fixed above the knee, to draw 



the limb downwards, in a direction opposed to the cords 
passed between the thighs. These last were of course 
so situated, the patient being on his side, that the ex- 
tension downwards might be forwards or backwards, 
and were entrusted to the hands of as many individuals 
as were required.* The necessary articles being arrang- 
ed, the longitudinal force was put in operation, by the 
hands of the assistants, and the lateral force by the pul- 
lies, both of them in the most gradual manner, so as 
not to excite the muscles to contract by sudden jerks ; 
but by a steady, long continued force, gradually to ex- 
haust their energy, and overcome their resistance to re- 
duction. While this was doing, I occasionally examined 
the situation of the head of the thigh bone, placed my 
hand thereon, and felt its movements, produced by the 
extending forces. I also requested some one or more of 
the consulting physicians to feel the head of the bone, 
with the intention of ascertaining whether its motions 
were such as to encourage us with the hope of its being 
approximated to its socket ; and they did one or more 
thus examine and recognise the movement of this part, 
with an expression of their opinion that the change of 
position was not considerable, nor sufficient to lead 
us to believe that the bone would be reduced. When the 
extension had been made for some time, I seized the ex- 
tremity of the limb, and operating with it as a lever, while 
the lateral force was still acting, made strong movements 
of the limb, with the intention of breaking it from its situa- 
tion, by destroying its newly formed adhesions of cellular 
membrane. Aware that dislocations had been often re- 

* At first view it might be thought unnecessary to extend, or 
lengthen, a limb already too long ; but, as we shall again state here- 
after, when a bone is thrown out of its socket, some of the muscles 
are over-strained, and draw the limb towards them, until it hitches 
or is engaged somewhere ; and these muscles confine it in its new 
situation, till their contraction is overpowered. The object of the 
application of force in a longitudinal direction, in such cases, is not 
to make the limb permanently longer, but to disengage it, so that it 
may afterwards be drawn or pushed into its natural place ; a change, 
that would be produced in this case, by the resisting muscles them- 
selves, provided the bone were previously disengaged. 



duced in a manner, the most opposed to that expected, 
even after judicious and scientific means had been tried 
in vain, I was studious that no practicable mode of 
operating should be omitted. The direction given to 
the limb was therefore varied in every possible manner ; 
and this practice I adopted with more decision, from re- 
flecting that if the limb were not restored to its place, 
yet the contraction of the muscles would be partially 
overcome by this process, the motions of the limb subse- 
quently increased, and the condition of the patient im- 
proved. Such was the course adopted during this 
operation. I -often questioned the patient as to the de- 
gree of suffering, and, on his declining any complaint, 
increased the application of force. After this had 
been continued an hour or more, with such changes 
as circumstances suggested, the patient appeared to be 
satisfied that the reduction was impracticable, and agreed 
to a discontinuance of the operation. The consulting 
physicians, being also of opinion that every warrantable 
effort had been made, advised to forbear any further 
attempt. At the time the force was about to be re- 
moved, I put in practice a recommendation, made, I 
think, by Sir Astley Cooper, for a dislocation back- 
wards, and which I had employed in a successful manner 
in a former case, of iliac dislocation ; namely, to pass a 
round towel, called by us a roller, between the thighs of 
the patient, to throw it over my shoulders, and then make 
an effort to raise the upper part of the bone, while the 
foot was carried inwards to the other. This affords a 
mode of operating in a very powerful manner. I found 
it not more successful than the other means employed, 
and therefore desisted from further trials. Thus termi- 
nated the operation, in the manner I had expected and 
represented. 

Although the means necessarily employed to give the 
patient a full experiment appeared to me severe, he sub- 
mitted to them most courageously, and never uttered a 
complaint, that I know of, at that time or since. In a 
day or two he was well enough to leave the hospital. 
2 



10 

From a publication made by him, after the last trial of 
his cause, I learn that he was so little appalled by the 
severity of the operation, and had suffered so little inju- 
ry from it, that after an interval of a single week, he 
was able and willing to apply to another practitioner of 
surgery, of much experience and skill, and to submit to 
another effort at reduction. This second trial having 
terminated like the first, he was induced, after the inter- 
val of a fortnight, to apply to a third operator, a per- 
son of reputation for his success in reducing dislocations : 
and he even a third time underwent the process of exten- 
sion. The result of this attempt was the same as that 
of the first and second. The efforts made in the two 
last attempts were, it is said, at least as forcible as 
those in either of the preceding 

By one acquainted with these facts, it would scarcely 
be credited, that the operation at the hospital was rep- 
resented by the attorney for the defendant in language 
calculated to excite the indignation of a jury, and to give 
them a strong prejudice against those who could advise 
and practise such cruel proceedings. * 

Some time after these occurrences, I met the patient, 
Mr. Lowell, in the street, and was accosted by him. 
He informed me that he was about to return home ; that 
he had thoughts of instituting a suit against the physician 
and surgeon, who were first called to him, and that he 
should be glad to have from me a statement of his case 
On hearing of this intention, I immediately remonstrated 
with Mr. Lowell. I told him that he ought not to 
blame his medical attendants, for his case was one of dif- 
ficulty ; that they had done the best they could for him ; 
and that if he trusted any medical man, the responsibility 
must rest with himself, for, if he had not confidence, he 
should not have employed the individual. To this he 
replied, that he would not desire to bring an action 
against the surgeon, had he done the best he could ; but 
that he thought himself grossly neglected ; that when 

* Vide Appendix, No. III. 



11 

he first suspected his limb had not been reduced, as 
it was thought to be, he sent for the surgeon, and was 
not able to obtain his attendance till a number of days 
afterwards ; that, when he did come, he acknowledged 
things were not right, but left him without making any 
attempt to rectify the difficulty ; and that he was, in 
consequence, a cripple for life. He thought he was en- 
titled to compensation for the injury he had suffered in 
being thus neglected. My answer was, that there were 
probably circumstances connected with this apparent 
neglect, not fully understood, and which would give a 
different aspect to the case ; that certainly I w T as of 
opinion he could not expect to recover damages in such 
a case, and therefore strongly advised and hoped he would 
lay aside all thoughts of a lawsuit, and must excuse myself 
from giving a statement, or in any manner interfering 
further in the affair. With this we parted, and I be- 
lieved that what I had said to him, would influence him 
to abandon the project of a prosecution.* 

* This conversation, apparently trivial, I have stated as minutely 
as I can remember it, because a story has been industriously propagat- 
ed in Maine and in Boston, that, not only was the lawsuit, instituted 
in this case, founded on the opinion I gave of the injury, but more- 
over, that I encouraged and stimulated the patient to seek reparation 
for his misfortune in this way. — Nothing can be more untrue. 
What possible motive could I have, for harassing an unfortunate 
practitioner with a lawsuit ? It is insinuated that I wished to gain 
some little eclat by contrasting my discernment with the ignorance 
of a remote practitioner, and that I expected to bring into notice 
the Massachusetts General Hospital, by the display of. an attempt 
to reduce an irreducible dislocation. As to the latter insinuation, it 
requires no answer ; and for the former I must, though with diffidence, 
assert, that I have always been desirous of supporting and aiding in- 
dividuals, and contributing my humble aid to improve the medical 
profession. Let it not be forgotten, however, that our first duties are 
to the public. It is for them we exist, and to them we are answera- 
ble. No one should be deterred, by the apprehension of giving of- 
fence, from a conscientious expression of his opinion, when it is really 
required. Dr. Hosack, in an inaugural address, has very justly re- 
marked, that " Coalitions, except when they are directed to mutual 
improvement, or the benefit of the community at large, are incon- 
sistent with, and a violation of, the solemn obligations which the phy- 
sician enters into, when he receives the Doctorate of Medicine. 5 ' 



12 

Some months after the conversation with Mr. Lowell. 
I received a letter from the practitioner chiefly concern- 
ed in this case, couched in terms apparently friendly, 
containing a request that I would give my opinion of the 
nature of this accident, and of the treatment he had adopt- 
ed. The writer was till this time unknown to me, even 
by name. Not being aware of the object of this applica- 
tion, and believing that he wished to clear himself from 
the effect of reports which might have been circulated in 
regard to the affair, I wrote a hasty and brief answer, 
and without changing the expression of the opinions I 
had already given, I said what I conscientiously could to 
relieve his mind, and to give him some means of show- 
ing to others, that I was not disposed, by my view of 
the case, to promulgate opinions, more unfavourable to 
his practice than I was compelled to do by a regard to 
truth.* This letter, written hastily, as a private 
communication, without any suspicion on my part of the 
existence of a legal process, was subsequently annexed to 
a deposition, which I was called on to give, and produced 
in court, and though it was objected to by the court, as 
not admissible, yet the attorney for the defendant has 
thought proper to print it in connexion with the trial. 

Perhaps the terms in which I endeavoured to frame 

There are instances when the declaration of a mistake on the part of 
a medical practitioner could be productive of no possible benefit to 
the patient, and might do harm to the physician. Under such cir- 
cumstances, silence would not only be proper, but necesssary. It 
must be a miserable mind that would devote to ruin the reputation 
and happiness of another, merely for the gratification of his own 
pride. Such individuals are sometimes seen; but happily they are 
few, and reap their reward in the frowns and aversion of all good 
and high-minded men. 

Although I have been led by these reports to advert to the topic, 
yet it is not, in fact, important to the subject of these remarks. The 
opinion I gave on this injury, was not meant to correct the error of 
another person. As I have already said, I had not a suspicion, when 
I formed it, that any physician or surgeon had been consulted in the 
case. My attention was fixed on the character of the injury, and 
the possibility of finding a remedy. Knowing no reason for con- 
cealment, I told the patient my opinion frankly and fully. 

* See Appendix, No. V. 



18 

an excuse for the practitioner, may be thought too little 
qualified ; my apology must be found in a sincere desire 
to prevent his suffering evil consequences, from what I 
then considered his misfortune, rather than his fault. 

So long a time elapsed after the letter, before I 
heard of this affair, that I did not expect to be troubled 
on the subject again. This ignorance on my part 
arose, as it appeared afterwards, from the distance by 
which the parties and myself were separated from each 
other, a space, of three hundred miles. At the expira- 
tion of about a year, more or less, from the occurrence 
of the accident, I received a letter from the patient, Mr. 
Lowell, in which he informed me that he had recent- 
ly been examined by a practitioner of surgery, of much 
experience and ability, who had declared in the most 
unequivocal language, that his hip was not out of joint, 
nor ever had been so. Mr. Lowell appeared to con- 
sider this opinion lightly. To me it appeared so extra- 
ordinary, that a practitioner, coming many months after 
others, who had examined the accident in the fullest 
manner, and with the most impartial intentions, should 
form an opinion directly opposite to the former, that I was 
incredulous on the subject. That another surgeon should 
differ from me concerning the kind of dislocation, con- 
sidering the infrequencj 7 of the species, would have excit- 
ed no surprise ; but the general symptoms of displacement 
had appeared to me as strongly characterized as those 
of any dislocation, of any joint, which had ever present- 
ed itself for my examination ; other persons had been 
equally well satisfied, and this at an early period of the 
derangement ; so that it may well be thought I was a 
little surprised at so unexpected a declaration. 

A suit, it appears, was instituted about this time, by 
the patient, against the surgeon and physician first called 
to administer to him. The nature and grounds of the 
charge made against these gentlemen, may be gathered 
from the testimony in the Appendix.* It seems that 

* Vide Appendix, No. I. 



14 

the medical practitioner first called, examined the injury, 
pronounced it to be a dislocation of the hip joint, made 
attempts to reduce it, and did, as he thought, succeed ; 
but the friends of the patient not being satisfied, an- 
other, more in the habit of surgical practice, was called 
from a neighbouring town, and took the management of 
the case. He examined the disordered limb, declared 
it not to be reduced, and proceeded to take measures for 
effecting its reduction. After a short time, he considered 
his efforts to have succeeded, and the limb to have been 
reduced. The patient was put into bed, with his knees 
tied together, and left in the care of the physician first 
called, who visited him daily ; while the surgeon, living 
at a distance, and on the other side of the water, saw 
him occasionally. After some time, the patient, finding 
his limb lengthened, and without its natural power of 
motion, became uneasy, and desired the attendance and 
examination of the surgeon. The latter, on his visit, 
seems to have declared himself not well satisfied with the 
appearance of the limb, but did not then, or at any subse- 
quent time, propose any important measures for reducing 
or improving it. 

On the first trial of this action, the jury gave a ver- 
dict for the plaintiff, and awarded $1900 damages. 
On a second trial, the verdict was again for the plain- 
tiff, damages $100. On a third, of which a report has 
been printed, the jury were not able to agree, except in 
acquitting the physician first called ; and one of the 
jurors, being unable to attend longer, on account of ill 
health, the parties agreed to withdraw, without costs 
on either side. The result of this last trial was, there- 
fore, in fact, favourable to the defendant. 

It would have been better, perhaps, if the affair had 
thus terminated. Unluckily, the attorney for the de- 
fendant, probably with his sanction, or at his request, 
thought fit to prepare and publish a report of this trial, 
with his argument at full length, containing statements 
and representations calculated to produce unfavourable 



.15 

and erroneous impressions in regard to the professional 
conduct of my colleagues and myself, and to bring ridi- 
cule on the institutions, with which we are connect- 
ed. In the investigation of a case of local injury like 
this, it would seem quite a flight of imagination to reach 
even the character of a hospital ; but the writer has 
brought within his compass the medical school, and 
University of this vicinity. Productions like this, in- 
volving the reputation of individuals, whether profession- 
al, or moral, are among those most eagerly read ; hence 
this " Report" has, with the aid of a little industry, been 
widely circulated. Its representations have had some 
influence on the public mind, and given some uneasiness 
to those concerned in the welfare of these institutions.* 

* The ingenuity displayed by the attorney for the defendant in this 
trial, was certainly very meritorious ; but it does not appear to have 
been necessary to blazon it by a publication of this description. Es- 
pecially, when the display was to be made at the expense of pro- 
fessional men, against whom there could be no crime charged, — un- 
less it were one to perform a charitable act, in the course of their 
official duty, and afterwards to state their knowledge of the fact, In 
obedience to the call of public justice. The attorney for the defend- 
ant has in his advertisement said, " There can be no doubt of the 
respect entertained for the eminent talents and virtues of those dis- 
tinguished individuals, whose opinions are commented on, or con- 
troverted." If this general remark were sincere, why did he think ft 
necessary to put the names of these individuals in print, in connexion 
with terms of ridicule ; and to send them thus throughout the nation, 
and, as far as he is able, to posterity. A person of discernment co'dd 
not but be aware of the probable operation of such a pamphlet, in the 
possession of the evil spirits of society. The writer has indeed as- 
signed, as a justification of the proceeding, that a partial account of 
this case had been recently published by the plaintiff, and that it was 
consequently necessary to prepare one more complete and just. The 
account published by the plaintiff was in truth little more than an ex- 
pression of his feelings, under the influence of recent disappointment. 
Having in himself the full conviction of the reality of an injury, of 
which the existence had been ridiculed in a court of justice, be 
printed a pamphlet in the form of an " Appeal" to the public, in order 
to convince them of his true condition, and to relieve himself from 
that state of excitement, produced by the final, and irremediable failure 
of hopes which he had long been accustomed to cherish. The pub- 
lication on the other side, is of a very different character. It is not 
the work of one of the parties concerned, but that of the attorney, 



16 

Previously to the occurrence of this third trial, I was 
visited by the plaintiff, for the purpose of obtaining 
my deposition to the facts which had come within 
my knowledge. On learning the object of this visit, 
I declined any agency in his case. I stated to him, 
that all the service in my power had been rendered, 
and that I thought myself fairly entitled to be excused from 
further trouble, especially as I had discouraged the suit, 
and did not feel justified in taking any measures, likely 
to operate against the defendant; he being of the same 
profession with myself, and therefore entitled to a 
reasonable degree of fellow feeling. He replied, that 
he was an injured man, and must have justice, and 
that for this purpose, my deposition was essential. 

He left me without obtaining my consent to give the de- 
position, and soon after, a notification was received from 
Lemuel Shaw Esq. to appear at his office, and answer to 
certain questions proposed by the parties on either side. I 
did not appear on this notice, but applied to Mr. Shaw 7 , on 
whose science and integrity I could repose the most perfect 
confidence, with a view to ascertain whether I could be 
compelled to answer in such case. This gentleman in- 
formed me that I must either appear to give testimony, 
or be responsible to the party aggrieved by my non- 
attendance, to the amount of damages by him sustained. 
A summons was afterwards issued, and money tendered 

who had already obtained all he had a right to ask for. It is a pub- 
lication of some stud}' and ability. Impartial men must undertake to 
judge whether a sudden display of feeling on the part of the plaintiff 
afforded a sufficient ground to justify the publication by the attorney 
for the defendant of a report, containing imputations, not only on the 
defeated and unfortunate plaintiff, but also on various professional 
persons, to whom he happened to apply for assistance. It would 
have been perhaps more judicious in this ingenious gentleman and 
his client to have been satisfied with success, and not have looked for 
revenge. They would then have spared me this disagreeable task, 
which nothing but the necessity of self defence would have compelled 
me to undertake. The statements made on the trial, which I have 
now been obliged' to combat, might have stood well with the world 
always, for aught I should have done, had the defendant and his 
friends abstained from this and their other publications. 



17 

in legal form, as is usual in cases where the attendance 
of a witness is to be compelled. 

Accordingly I appeared, and submitted to a series of 
interrogatories and cross interrogatories, which occu- 
pied about three hours. My answers were made ac- 
cording to the best of my knowledge, and recollection 
at the time ; and comprehended an account of the facts 
of the case, already stated, with some others. The 
substance of these answers was nearly this : That I did 
at a certain time attempt to reduce the dislocated limb 
of the plaintiff, in conjunction with other physicians and 
surgeons named ; — that the reasons for believing the ex- 
istence of a dislocation in this case, were, the unnatural 
position of the limb ; its elongation ; the accompanying 
contraction of the thigh and leg ; the displacement of the 
trochanter ; the displacement of the head of the thigh 
bone, and its appearance in an unnatural situation, in or 
near the ischiatic notch ; the inability to use the limb in 
the ordinary manner, and the consequent necessity of 
extraordinary and constrained movements ; — that manual 
force might succeed sometimes, in reducing dislocations 
of the hip joint, and that when this failed, mechanical 
means must be employed ; — that the elongation of a dis- 
ordered limb might be produced, to some extent, by simple 
relaxation of muscles, or by relaxation of muscles accom- 
panied with fracture of the bone ; — further, that the thigh 
bone, after being reduced, might be thrown out again, by 
the application of considerable force, or by movements of 
considerable extent, but not otherwise ; — that a surgeon 
w r ho employs the best means in his power, ought not to be 
responsible in damages; — that a surgeon who has oppor- 
tunity to examine a case of dislocation, immediately af- 
ter the injury, other circumstances being equal, has bet- 
ter means of judging of the nature of the case, than one 
who examines several months after ; — that the case in ques- 
tion, though not without its difficulties, appeared to me to 
be one, in regard to which, men of high standing in the 
profession w 7 ould not differ. The manner in which the 
3 



18 

reduction was attempted, was also described, though with 
less minuteness than as I have now described it. 

The questions proposed to me were also proposed to 
three of the consulting physicians, who had examined 
the case with me. The coincidence of their opinions 
with mine, at the distance of more than two years from 
the occurrence described, affords a strong proof of the 
authenticity of the evidence, and the distinctness of the 
most important impressions made by this case on each 
of the individuals questioned.* 

In the representation I gave of this affair, it is obvi- 
ous that there was no disposition shown to bear more 
severely on the defendant than regard to truth demand- 
ed; that on the contrary, I was disposed to admit what- 
ever might tend to afford him the fullest opportunity for 
self-defence. This course would, to many persons, seem 
to call for a corresponding demeanour on the part of 
those employed to defend the accused ; but so far from 
this, the attorney for the defendant, not contented with 
the performance of his professional duty, that of exerting 
every effort to prove our conclusions to be groundless, has 
treated us in the manner considered allowable in courts 
of law, in the case of witnesses guilty of prevarication, 
malicious design, or gross falsehood. This course must 

* The attorney for the defendant has not neglected the opportuni- 
ty of insinuating that there is something suspicious in this concur- 
rence of testimony. " This circumstance is barely noted," he says, 
" at this moment, in conjunction with the memorable coincidence of 
opinion expressed by the learned faculty at Boston. In this view 
however, it becomes quite edifying to observe the exquisite harmony 
prevailing in the sentiments of the other parts of the choir, swelling 
altogether beyond the gentle cadence of their candid precentor, that a 
dislocation of this nature was not altogether without its difficulty." 

For this insinuation of a collusion between the other gentlemen 
and myself, there is as little ground as for other imputations thrown 
out in the course of the remarks of the attorney. The truth is, that 
I never saw the depositions of either of these gentlemen, and two of 
them certainly could not have seen mine ; for their depositions appear 
to have been taken previously to it; nor has any other communication 
on the subject existed between us, from the day of the consultation 
in the Massachusetts General Hospital, in the month of December 
1821, to the moment when I am writing. 



19 

be considered very objectionable, for the whole medical 
profession are liable to be called on for opinions, which 
w T ould equally expose them to such treatment, if they 
happened to fall into the hands of persons inclined to 
practise it. 

The attorney does not seem to be justified in his pro- 
ceeding by an appearance of excessive confidence in the 
opinion I had occasion to express ; although he has 
freely imputed such confidence. I stated, that " this 
dislocation was one difficult to discover, but one in re- 
gard to which / thought men of high standing in the pro- 
fession could not differ." Could I have spoken less 
confidently in regard to any case, in w T hich I had made 
up an opinion at all, especially after two several private 
examinations, confirmed by a third in public ? 

A specimen of the kind of language, to which I allude, is 
contained in the following extract from the argument of 
the attorney for the defendant. In this part of his address, 
there are not indeed any personal allusions of an extra- 
professional kind, but the quotation will exhibit the 
manner of the orator, and show whether he is authoriz- 
ed to charge others with too much confidence. 

" Taking the account given by Dr. Warren of their reasons as the 
text — and reading their result by its own light, there needs no more 
satisfactory test for trying its own truth. Its condemnation shall 
come out of its own mouth ; and on a critical examination it will not 
only prove to be & perfect fallacy — and shown to be a most egregious 
error, but demonstrated to be one of the most absurd, unaccountable, 
and incredible description. Its refutation can be established upon 
the most obvious principles of anatomy, which it will appear, have not 
only been disregarded by these learned doctors, but that their con- 
clusion has been adopted in absolute defiance of them — a hallucina- 
tion of the most extraordinary character itself — such as could hardly 
have been expected of a surgeon of three months standing." 

To this language I shall reply by an investigation of 
facts. 

In order to show what opinions the orator intended to 
convict of such perfect absurdity, it would be desirable 
to give his allegations and arguments in his own lan- 
guage ; but, such is the character of his harangue, as to 



20 

render this impracticable. It may be gathered from it, 
■that his object is to prove two allegations : 

1st. That no dislocation existed in the case of Mr. 
Lowell. 

2d. That such a dislocation as I supposed to exist in 
this case, is, according to the authority of Sir Astley 
Cooper, impossible. 

By the aid of a deposition from a gentleman of high 
standing in the profession, showing that, in his opinion, 
no dislocation existed, and by presenting the authority 
of Sir Astley Cooper in a light favourable to his ob- 
ject, the attorney prevailed so far as to obtain a disa- 
greement of the jury. Any jury must indeed have been 
greatly influenced by the consideration, that one surgeon 
of eminence doubted the existence of a dislocation ; for 
a doubt from such a quarter would alone seem sufficient 
to exonerate the defendant from the charge of ignorance, 
or at least partially so. 

The charge of negligence, the only ground, as it 
seems to me, of accusation, that ought to be maintained 
in such a case, does not appear to have been much in- 
sisted on, by the attorney for the plaintiff, at least if 
we are to judge by this " Report." 
. My design, it will be perceived, is not to prove the 
criminality, or inability, of the defendant. With his 
practice I wish to have nothing to do. The object I 
have in view is to defend myself against the allegations 
mentioned above, and against the means employed to 
support them. I shall, therefore, proceed to examine 
them successively : and, 

First, whether a dislocation did actually exist in the 
present case. 

The appearances which led me to believe, that there 
was such a dislocation, I have already stated. It is 
therefore proper to inquire, what are the grounds on 
which the opinion, thus given, has been proved or sup- 
posed to be erroneous ; and they appear to be constitut- 
ed by the depositions of four medical men. 

It seems that about six months after I had seen this 



21 

case, and nine months from the occurrence of the acci- 
dent, the plaintiff was examined by a surgical practitioner 
of much reputation and experience, who pronounced 
that no dislocation did then exist, and he moreover 
intimated that none ever had existed.* Another practi- 
tioner was present at the examination, who agreed to this 
opinion. After a period of two years or more, when the 
cause was for the third time on trial, two other gentlemen 
appeared in court, neither of whom, so far as we learn, 
had examined the patient, yet both of them made oath, 
that the accident was not a dislocation, but a fracture, 
or some other injury of the joint. 

The deposition first alluded to, which will be desig- 
nated as deposition A., being first in point of time, 
comes first to be considered. In commenting on this 
deposition, proceeding as it does from a gentleman of 
high standing in the surgical art, I feel some degree of 
embarrassment and reluctance ; yet, whoever considers 
the matter a little, will, I presume, see that I have been 
compelled to it by the publication of this trial, and the 
gross insinuations it contains. The gentleman in ques- 
tion examined the case six months after my colleagues 
and myself, gave an opinion wholly opposite to ours, 
and one tending to show we were in the wrong in every 
point. I do not say that he did so with this intention, 
but his opinion had this effect, and influenced others to 
take the same ground ; it was brought into court, served 
as an important instrument in the hands of the attorney, 
and finally was employed to assist in making a book, of 
which the obvious tendency is to injure our professional 
character. I hope therefore to escape the charge of a want 
of due respect, to a gentleman in advance of me in age and 
experience, if I examine the ground taken against me 
very fully, so long as the examination is conducted in 
a decorous and honourable manner ; and I trust that in 
doing this, I shall make use of no expression, which is 
not called for by the defensive nature of my position. 

* See the dep >sition marked A. in the Appendix. 



'22 

It is to be considered, that the circumstances attend- 
ing the accident of the plaintiff, were such as were like- 
ly to produce an injury of an important character, 
such as fracture of the bones of the thigh, or pelvis, dis- 
location of the former, &c. Several kinds of injury 
were prima facie to be regarded as probable consequen- 
ces of the fall. The subsequent phenomena showed 
that one or more of these actually existed, and every 
medical man, of many who examined the patient within 
a period of nine months from the date of the accident, 
had decided that the actual result was a dislocation of 
the thigh bone. The defendant indeed supposed this 
to be complicated with fracture of the socket, but all 
agreed in asserting its existence. The deponent A., 
however, was induced, by the result of an examination, 
made at the end of the above mentioned period, to con- 
clude that all his predecessors had been mistaken, and 
that the iujury was of a different kind. In order to 
have an adequate sense of the importance of this deposi- 
tion, it is further to be considered, that the question had 
become unusually important, and that the decision of 
the court concerning it was a matter of extensive interest, 
and likely to affect in various ways the property and char- 
acter of many individuals. In the testimony of a dis- 
tinguished person, given under such circumstances, we 
should expect a clear statement of the phenomena, which 
he considered inconsistent with the existence of disloca- 
tion, and of those, which in his opinion tended to prove 
that of some other possible derangement. We shall be 
able to estimate the force of the reasoning on these 
points better by reducing the substance of the testimony 
to distinct propositions. These are, 

1st. That the manner in which the accident happened, 
was such as to render it scarcely possible that the hip 
should be dislocated. 

2d. That some of the phenomena, as the lengthening 
of the limb, distortion, &c. which had been attributed in 
this case to dislocation, did in other instances, and might 
in this, arise from other causes. 



23 

3d. That the symptoms exhibited in Lowell's case 
differ in some essential circumstances, from those, which 
are exhibited by any one of three different species of 
hip dislocation. 

Which of these propositions points out any circum- 
stance of the plaintiff's accident, that in the opinion of 
the deponent is incompatible with the notion of a dis- 
location of the hip bone ? The first alone. The ar- 
gument is, that, since Mr. Lowell fell on his hip, the 
fall could not dislocate it. But Mr. Lowell informed 
me and others, that he fell on his back, and Reynolds, 
the only witness of the circumstances of the fall, swears 
positively to the same effect.* The deponent therefore, 
being misinformed in regard to a fact, his opinion, so far 
as it rests solely on this fact, is without weight. 

The second proposition points out nothing inconsist- 
ent with dislocation. The phenomena detailed belong 
to dislocation. They belong also, according to the de- 
ponent, to other derangements. I shall hereafter en- 
deavour to make it appear, that, in the manner and de- 
gree in which they existed in Lowell's case, they could 
not be accounted for, on the supposition of any other 
cause than dislocation. I might safely admit, however, 
for the present, that they could, for this would prove on- 
ly that Lowell's injury might be fracture, hip disease, 
or something else, not that it was not dislocation. 

The remaining proposition goes to prove merely, that 
the bone in this case could not have been dislocated in 
any one of three different directions mentioned by the 
deponent. It will hereafter be seen that I agree with 
him in this opinion. Still there is nothing decisive 
against the existence of dislocation, unless it be asserted, 
that it is possible in no other direction, which the de- 
ponent nowhere says. 

The whole of this part of the evidence of the depo- 
nent is evidently connected with the first proposition. 
Conceiving it impossible that a dislocation should result 

* See the deposition of Reynolds. Appendix, No. II. 



24 

from a fall on the hip, he was naturally led to seek for 
some other probable explanation of the phenomena. 
This singular difference of opinion is therefore to be 
traced to incorrect information. 

This is equally obvious when we consider the evi- 
dence, contained in the deposition, in another point of 
view, that is, as it sets forth the circumstances, which, 
in the opinion of the deponent, are decisive of the ex- 
istence of a particular species of injury. The only one 
offered is a sort of corollary from the first of the above 
propositions. " A fall on the hip," &c. says the depo- 
sition, " might drive the head of the bone through the 
socket," &c. and "in my opinion, if there is any de- 
rangement of the bones, it is a fracture." The " fall 
on the hip," again, is the only decisive circumstance in 
favour of fracture. 

It is not necessary for me to point out the incorrectness 
of the deponent's inference from the supposed fact. It 
is not expected of any one to draw correct conclusions 
from false premises, and it must be obvious to every 
reader, that the deponent was under the necessity of 
coming to an erroneous conclusion. 

My situation as defendant in this affair, obliges me 
further to remark upon two other opinions which ap- 
pear in this deposition. They have not indeed a direct 
bearing upon the present question of the existence 
of any dislocation. But they are likely to have an 
influence upon the judgment of the public in regard 
to it, since, if correct, they prove that the opposite 
opinions, previously expressed by me, are unfounded, and 
thereby go directly to diminish the confidence in my 
testimony. I refer to the deponent's opinion concerning 
the length of time after the accident, which may render 
it difficult or impossible to restore a dislocated limb, and 
to the opinion concerning the use of pullies : 

" I should not think," says the deponent, " that a hip 
joint having been out of place six or even eight weeks, 
would render it impossible to reduce it. It might even be 
a more favourable time for the operation, than immediate- 



25 

ly after the accident, especially if the soft parts were 
much bruised and swollen." This doctrine appears new 
to me, I must confess, and will probably be so to most 
surgeons. It has been generally thought to be of primary 
consequence to effect the reduction of a dislocated bone 
with the least possible delay ; because, independently of 
all reasoning, experience has taught, that the difficulty 
is less during the first hour, than during the second, and 
so on ; and that a dislocation which might be reduced 
with ease the first day, would present a great resistance 
the next. No practical axiom has been more generally 
adopted, therefore, and none more firmly established, than 
that which teaches the necessity of immediate surgical 
aid in such injuries; and what was before established 
by experience, has been confirmed by the discovery of 
the principles which operate in producing dislocations, 
and which ought to govern the attempts to remedy them. 
To the school of Hunter we are indebted, I believe, for 
the more distinct knowledge of the fact, that the great 
obstacle to the restoration of a dislocated bone is to be 
found in the resistance of the muscles. In the passage 
already quoted, Mr. Hunter lays down as a principal 
indication in the reduction of dislocations, that we are 
" to overcome the muscles, which draw up the dislocat- 
ed bone, and resist its recovering its natural situation." 
The old opinion that ligaments only prevented the bone 
from returning into its socket, is generally abandoned, 
as it has been well ascertained, that there are but a few 
instances where they prevent a bone from obeying any 
external impulse after these accidents. In a complete 
dislocation of a capsular joint, such as the shoulder or 
hip, the ligament is in most cases extensively torn ; a 
part of it usually remains connected with the bones, 
and this part helps to retain the bone in its new situa- 
tion, though not sufficient to do it of itself. In joints, 
confined only by lateral ligaments, as the fingers, a 
dislocation may take place without a rupture of the 
ligaments, and, when this happens, the resistance will 
be made by these, and not by muscles ; whence it has 
4 



26 

been proposed to divide one of these ligaments, in the 
case of an irreducible dislocation. 

Having made these remarks to explain how far the 
action of the ligaments appears to be admitted as a cause 
of resistance, it may be repeated, that the doctrine 
generally received at the present day is, that the mus- 
cles are the principal agents in producing and maintain- 
ing dislocations. In causing dislocations, by a well 
intended effort of nature, they act in a violent and 
unexpected manner ; using the bone as a lever, and 
an exterior body as a fulcrum, so that the bone is dis- 
placed more by their action, than by the external vio- 
lence. In retaining the bone in its new place, they 
are governed by the disposition, common to every 
healthy muscle, to shorten itself as much as possible.* 
Whenever a bone is thrown from its socket, the situa- 
tion of most of the muscles about it is altered ; some of 
them are lengthened and others shortened. The latter 
immediately begin to contract, in order to accommodate 
themselves to their new situation ; and as soon as they 
have attained the degree of contraction their state per- 
mits, their relations to the joint are changed, they are 
no longer in a condition accommodated to its ordinary 
structure, and oppose a return of the bone to its place* 
The muscles, on the contrary, whose two points of at- 
tachment are removed further from each other, are elon- 
gated and overstrained to such a degree, that they would 
immediately draw the bone back to its proper place, were 
it not hitched on some bone or muscle, but this being the 
case, their contraction, instead of restoring the bone, 
does indeed confine it in its unnatural situation, and tends 
to prevent its being disengaged. In the dislocation of the 

* When the knee pan is broken, the muscles connected with the 
upper fragment of the broken bone, draw it upwards several inches; 
their action in this, is analogous to that of a spiral spring, drawn out 
and then abandoned to its elastic power. 1 he same occurs in the 
rupture of the Tendo achillis near the heel ; the upper fragment of 
muscle contracts, and leaves an interstice between the divided parts. 
The laws governing the muscles in such instances, exert their influ- 
ence in dislocations. 



27 

thigh bone downwards, the Psoas magnus, Iliacus inrer- 
nus, and part of the Gluteus medius are put on the strain. 
It appears that on the occurrence of a dislocation, the 
bone is confined at first by the overstrained muscles only, 
as, in the instance named, by the Psoas, Iliacus, and Glu- 
teus ; but after the other muscles have had time to con- 
tract, these also add their powers to that of the first, and 
incalculably increase the resistance. There is another 
way in which muscular action may be concerned. It is 
when the bone, in its passage from the socket, perfo- 
rates a muscle, or forces its way between two muscles, 
and the muscular fibres contract about and embrace it. 
This is probably the case in many of those instances, in 
which, after the unsuccessful exertion of a powerful force 
upon a displaced bone for a considerable time, a slight 
movement effects its sudden restoration, by accidentally 
bringing the head of the bone to the rent in the mus- 
cles. Sudden reductions, I imagine, often happen in 
this manner ; though they may arise from simply disen- 
gaging one bone from another, and sometimes, but more 
rarely, from the bone having been confined by its 
ligament. 

A knowledge of the principles alluded to, will show 
the vast importance of an immediate reduction in most 
cases of displaced bones. The practice ought not to be 
lightly abandoned, because the soft parts are swelled. 
The swelling of the soft parts at first, exists principally 
in the cellular substance, which can oppose no consider- 
able obstacle to the movements of a bone ; but, if the 
operation be delayed, the muscles also may swell, and 
add a new and insuperable difficulty to the reduction.* 

* As a wrong opinion on a practical point of so much consequence 
might have an unhappy influence on the fate of many persons, and 
the reputation of many young practitioners, 1 shall beg leave to in- 
troduce from Sir Astley Cooper some remarks on this subject, for 
the benefit of those who may not have access to his treatise. 

u Of the various accidents which happen to the body, there are 
few which require a more prompt assistance, or which more direcily 
endanger the reputation of a surgeon, than cases of dislocation. If 
much time elapse before the attempt at reduction be made, the difii- 



28 

Sir Astlet Cooper relates indeed a very extraordi- 
nary instance, at first view opposed to what has been 
just said, of an individual who put his hip in accidentally, 
after it had been out a number of years. This case does 
not, however, afford much encouragement for delaying 
the operation ; for the reduction had been unsuccessfully 
attempted by a number of eminent surgeons. Such ex- 
traordinary events ought to have no influence in opposi- 
tion to the maxims drawn from the experience of every 
day ; and I earnestly hope that practitioners will not 
risk their reputation, and the happiness of their patients, 
by an hour's delay in these cases. In regard to hip 
dislocations, I must say there is the strongest reason 
to believe, that the intervention of a few days between 
the accident and the operation will form insuperable ob- 
stacles to the reduction of such dislocations in the great- 
er number of cases.. 

In the attempt made at the Massachusetts General 
Hospital to reduce this dislocation, it was thought prop- 
er to employ the dislocation pullies provided for such 
purposes. The deponent takes occasion to speak of 

culty of accomplishing it is proportionably increased, and it is not un- 
frequently totally impracticable; and, if the nature of the injury re- 
main unknown, and the luxation consequently unreduced, the patient 
becomes a living memorial of the surgeon's ignorance, or inattention. 
In a dislocation of the os femoris, which still remains unreduced, a 
consultation was held on the nature of the injury, and, after a long 
consideration, this report was made by one of the surgeons, ( Well, 
sir, thank Heaven, we are all agreed that there is no dislocation P — 
I am of opinion, that three months, for the shoulder, and eight weeks, 
for the hip, may be fixed as the period from the accident at which it 
would be imprudent to make the attempt at reduction, except in per- 
sons of extremely relaxed fibres, or of advanced age. At the same 
time, I am fully persuaded, that the shoulder has been reduced at a 
more distant period from the accident than that mentioned, but in 
most instances with the results I have been deprecating. 

" In very strong muscular persons, I am not disposed, after three 
months, to make the attempt, finding that the use of the limb is not, 
when reduced, greater than that which it would have acquired, by 
having remained in its dislocated state. Let this be fairly represent- 
ed to the patient, and then, at his request only, the reduction should 
be attempted." 



29 

their use in the following terms. " I do not think that 
the mechanical powers, such as the wheel and axle, 
or the pullies are necessary to reduce a dislocated hip, 
or any other dislocation. They have been sometimes 
used with effect, but they have oftener been injurious ; 
and what can be effected with them, can be effected 
without them. It is not the quantum of force which 
reduces dislocated bones, so much as it is the direction 
of the force, and this can be given by the hand of skill 
better than by pullies," &c. These remarks would be 
perfectly just, if the principal opposition to reducing a dis- 
location, was made by the ligaments of the injured joint ; 
but, as we have already said, it is now generally under- 
stood by surgeons, that the greatest obstacle is muscular 
contraction. The power exerted by the muscles in such 
circumstances, is known to be very great, and requires 
a great force to counteract it. When a bone is displaced, 
some of the muscles, as we have already show 7 n, are 
shortened, and contract to accommodate themselves to 
their new condition ; others are put on the stretch, in 
consequence of the hitching of the bone in an unnatural 
situation. The last description of muscles are, imme- 
diately after the accident, the most efficient causes oppos- 
ed to the restoration of the bone. The first object to be 
considered in the attempt to bring the bone to its place, 
is the application of a power in such a direction as to 
overcome these muscles, not by sudden, violent efforts, 
but by a gradual force. When they are strong, this ap- 
plication of force can be more effectually made by pullies, 
than by the hand, for the muscular resistance is so great, 
in such cases, as not to be overcome but by pullies, or the 
hands of many men. The power of a number of persons 
cannot be exerted steadily, their strength is soon exhaust- 
ed, and the degree of force applied, must therefore, con- 
stantly vary ; the muscles of the patient, instead of being 
overpowered, are stimulated to contract with additional 
force, by this irregular action. Pullies, on the contrary, 
act steadily and uniformly, until the muscles, on which 
they draw, are perfectly extended. The degree of 



30 

power applied, may be tolerably well measured by the 
observation of the surgeon, and increased or diminished, 
as may be necessary. Here is no interference of a 
multitude of assistants with each other ; no bustle, no 
unnecessary violence. The direction of the force may 
be so adapted, as to act on the muscles that resist, and 
not on others. The only advantage possessed by manu- 
al force, which pullies have not, consists in the facility 
of varying the direction of the powers, so as not only to 
overcome the muscles whose action is visible, but that 
of others, which is not so obvious ; and moreover, by 
these changes to succeed in bringing the head of the 
bone to the interstice of the muscle, or to the rent in the 
ligament, through which it may have passed. These 
advantages may be acquired, however, in an easier way, 
by overpowering the muscles by pullies first, and after- 
wards, if necessary, varying the direction of the limb 
by the hand. These instruments are therefore of great 
use in many simple dislocations, and, in such as are ex- 
traordinary and difficult, they are indispensable. I am 
well satisfied that many bad cases of dislocation of the 
hip can never be reduced without their aid. As to in- 
jurious consequences arising from them, I must say, 
that, though every powerful instrument may be abused, 
I have never seen any ill effects from pullies, nor do I 
perceive that any such can occur, without great inatten- 
tion.* Sir Astley Cooper, and most surgeons of the 
present day, very strongly recommend their use. The 
wheel and axle I have not heard of as being employed 
in modern days.f 

Besides that of the deposition A, which w r e have been 
examining, it has been observed, that there was also the 
negative evidence of three other practitioners. That of 
one appears in the form of a deposition ; that of the others 

*It must be understood, that exception should be made for cases, 
the circumstances of which might justify a great and even dangerous 
application of force. 

t There is one other point in the deposition, to which I am induced 
to advert, from unwillingness to allow a stigma to attach to the mem- 



31 

in the form of testimony in the court of justice. The 
weight to be attached to these will be the next object of 
our investigation. Of the three it appears that only one did 
ever actually examine, or rather see the examination of the 
patient, and, of course, the opinions of the others are of 
comparatively small importance. I shall first consider the 
evidence of the former, contained in the deposition B.* 
From this it appears, that the deponent B. was pres- 
ent with the deponent A., " at an examination of Charles 
Lowell, for a disease, or affection of the left hip joint," 
and he says, " I am of opinion, that it does not arise 
from dislocation at present existing ; but from affection 
of the muscles, or some other cause." That is, the de- 
ponent was present at an examination in which a most 
strange mistake made by a number of surgeons, was de- 
tected and exposed ; and yet, so far as we can discover, 
did not put his finger to the affected part. For there is 
nothing in his deposition which would lead us to believe 

bers of the medical profession in this country, which I cannot think 
merited. 

Question, by the defendant's attorney. * Ts the dislocation of the 
hip joint an unusual occurrence ? and might a skilful surgeon fail in 
any attempt to reduce it ?" 

Answer. " A dislocation of the hip joint is very rare, and probably 
not one medical man in ten would be able to reduce it." 

Lamentable indeed must be the condition of surgical science in our 
New England states, if only one practitioner in ten is able to reduce 
a dislocation of the hip. Can we boast no better fruits from our six 
medical schools, from all our state medical societies, and our district 
medical associations 1 The mode described by the deponent with so 
much candour, as having been employed by himself, does not appear to 
be a process very difficult to imitate. " I once," says the deposition, 
'•reduced a hip joint; it was dislocated upwards and backwards; 
and after pulling it in every direction but the right, it was reduced 
easily by carrying the knee towards the patient's face. I had the 
assistance of two men only." This operation might be practised 
easily by persons of les^s surgical knowledge. If the medical men of 
this and the neighbouring states were questioned, I imagine they 
would tell us, that not one in ten would fail in reducing a dislocation 
of the hip ; making due exceptions for cases of peculiar difficulty,, 
such as those of the ischiatic notch, and those, in which the accident 
was overlooked or mistaken for a different kind of injury. 
* See, in Appendix, deposition B. 



32 

that he did more than stand by and witness the exami* 
nation made by another person. Was it not natural for 
the deponent A., on making the discovery that the ima- 
gined dislocation did not exist, to express himself 
strongly to the deponent B., and to request him to ex- 
amine for himself; to point out to him the exact situa- 
tion of the different parts concerned, and desire him to 
touch them, that there might be no mistake ? and would 
it not be expected that B., in his turn, should have drop- 
ped some expressions of surprise ? and would he not 
have repeated these expressions in his deposition ? We 
hear nothing of this.* The deponent A. made his exami- 
nation, drew a number of lines about the joint, while the 
deponent B. remained merely present, and seems to have 
felt very little interest, in a most extraordinary occurrence. 
How are we to understand all this ? The deponent B. 
it is intimated in the pamphlet of the plaintiff, had been 
a pupil of A., and consequently perhaps, submitted wholly 
to his judgment. If this be the fact, we cannot be sur- 
prised at the posture he assumed in the affair. But, 
while it may be said he was right in yielding his judg- 
ment to that of a person of superior experience, we must 
be excused for not admitting that this opinion adds any 
weight to that of the former. There is another point 
of view, however, in which we cannot so fully exonerate 
the deponent ; for, although he does not inform us that 
he examined the nature of the injury, yet, it appears, he 
was able to get an opinion concerning it, not of a very 
positive character indeed ; which he thus expresses, 
" That it (the disease or affection) does not arise from 
dislocation at present existing, but from affection of the 
muscles, or some other cause " Does not this language 
amount nearly to saying, that, though he could not pre- 
tend to state what this disease, or affection was, he was 
willing to believe that it might arise from an affection 
of the muscles, or from some other cause, but was de- 
termined not to believe the existence of dislocation. 

* See testimony of Theodore Lincoln, annexed to deposition A, 
in Appendix. 



33 

The testimony of the witness C.,* I shall not criticise 
very minutely, as the circumstances, under which it was 
given, and the fact of his never having examined the 
patient, render it of little consequence. " From the 
nature of this testimony," says the attorney on the same 
side, "it is not capable of being perfectly reported." 
The difficulty of reporting it is explained in the pamphlet 
of the plaintiff, who tells us, that both this practitioner and 
the witness D., were said to be threatened with a similar 
prosecution, if this succeeded, and that, from this, or some 
other cause, the witness laboured under great agitation. 
For this feeling he is not blameable ; but what shall we 
say to the testimony of a witness, who never saw the ob- 
ject, of whose existence he would testify. He ventures 
to give an opinion, " that the plaintiff's injury was a 
fracture^ not a derangement of the bones of the pelvis." 
Yet this fracture, and derangement, he had never seen, 
nor had he any precise means, that we hear of, of judg- 
ing of their existence. The same remark may be ap- 
plied to the testimony D,t which informs us, that the 
plaintiff's case " was an injury of the bones of the pel- 
vis." He had no better opportunity of ascertaining the 
real state of things, than the witness C. Neither of 
them, as is positively stated by the plaintiff, ever ex- 
amined him. 

It appears that of all the medical men who did 
examine him, not one doubted that his hip was dislo- 
cated, except the deponents A. and B., both of whom 
saw the patient nine months after the accident. We 
have already seen that these two are reducible to one ; 
and that the deposition A. gave rise to all the others. 
Thus we have the imposing testimony of four medical 
practitioners, really reduced to that of one individual, 
who, as we have seen, was in this particular instance, 
misinformed in regard to the circumstance upon which 
his opinion was principally grounded. 

The examination of these depositions and testimonies, 

* See Appendix, C. f lb. D. 



34 

will satisfy most men, probably, that while an inclina- 
tion is displayed to make use of every fact and circum- 
stance, to combat the opinions rendered by my colleagues 
and myself, yet the arguments adduced in supporting the 
adverse doctrines have no solidity. If this be true, I 
might here leave the question of the existence of the 
dislocation, to be decided by the impartial ; and I should 
be contented so to do, were it not necessary to use 
every honourable means to repel so gross an imputation 
as that of subjecting an individual to a cruel operation, 
from an ignorant, or hasty investigation of his case. I 
cannot therefore properly omit any thing which may tend 
to present the true state of this affair in a stronger light, 
and to clear myself from a charge so odious. 

Besides those already employed, there seem to be 
two other tests, to which this question may be subject- 
ed. The first is, the general agreement of the symp- 
toms exhibited in this patient, with the signs of disloca- 
tion ; and their want" of agreement with those of any 
other injury of the hip. The second will be found in a 
comparison of the weight of opinion on the opposite 
sides of the question. 

In many cases of dislocation, the changes in the ex- 
ternal appearance of the joint are such as to enable us to 
infer with certainty the displacement of a bone, though 
they may not show at first view, in what direction it 
has happened. This is especially true in regard 
to the hip joint. At present, therefore, it may be best 
to examine the general phenomena of these dislo- 
cations, without attempting to settle the characteristics 
of any species. The latter must be made a distinct 
and special subject of consideration. 

In studying the external appearances indicative of the 
displacement of a bone, a kind of knowledge is required, 
which is not to be found in books. It may be called 
the anatomy of the superficies of the body, and consists 
in an acquaintance with the appearances made on the 
surface of the body, by bones, muscles, and other parts. 
Our students consider it essential to qualify themselves 



35 

thoroughly in the science of the interior arrangement of 
these organs ; yet, when called for the first time to the 
examination of an injured joint, they find that the know- 
ledge, of which they had fancied themselves possessed, 
has vanished from their sight, and left them an obscure 
and confused group of appearances, among which they 
cannot with certainty discriminate a single object. For 
many years I have been in the habit of impressing this 
subject on the minds of those gentlemen, whom I have 
had the honour to instruct ; and though I am not cer- 
tain, that it has gained the attention which its importance 
merits, I am confident that these lessons have not been 
without their influence in practice. By having pointed 
out to them the prominences of the joints in different 
parts of the body, they learn to observe with more care 
the external appearances, accustom themselves to the 
impressions made on the senses of vision, and touch, 
and thus become prepared to notice the changes in the 
aspect and relations of all these parts, when disturbed 
or displaced by accident or disease. The condition of 
an articulation is sometimes so strangely altered by in- 
juries, that the most scientific eye, and the most prac- 
tised hand, seek in vain to ascertain with precision, the 
changes which have taken place. But this obscurity may- 
be cleared away in most cases ; for with sufficient pa- 
tience and careful observation, the anatomist will rarely 
fail of satisfying himself of the real state of the injured 
parts. The advantages of the kind of information noticed 
above, I have been accustomed to enforce by referring 
to the skill of those who, practising without a knowledge 
of anatomy, and therefore constantly liable to do wrong, 
yet often succeed in doing right, where the most scien- 
tific surgeons have failed. 

This kind of knowledge of external parts is absolute- 
ly necessary in trying the question now at issue ; for, 
as we cannot see what the interior state of the organs 
is, in a dislocation, we must judge of it by external signs. 
These signs may be supposed to be fallacious ; and this 
is true in regard to a part of them ; while others are t® 



36 

be considered as carrying with them much the same 
certainty as ocular inspection of the bones and muscles. 
To obtain a statement of these symptoms, we must have 
recourse to works creditable not for their scientific 
character only. They must also be popular works ; that 
is, such as contain facts considered to be admitted by the 
medical world. As one, which combines these qualities, 
I shall select the work of Mr. Samuel Cooper. In the 
part relating to the subject we are upon, he gives us a 
translation from Boyer, so far interwoven with his own 
opinions, as to afford us the advantage of the doctrines 
of the able French surgeon, admitted and adopted into 
a standard English work. 

" The general symptoms termed by Boyer positive, 
or actually present, are, says Mr. Cooper, numerous and 
clear." We shall state them, in order that they may be 
compared with those of our patient. 

" 1. In dislocations of orbicular joints" (as the shoulder 
and hip) " and complete luxations of ginglymoid joints," 
(as the elbow and knee) " the orbicular surfaces are not 
at all in contact, and the point where the dislocated bone 
is lodged, cannot be on the same level with the centre 
of the cavity from which it has been forced. Hence a 
change in the length of the limb. 

" 2. In almost all complete luxations, the direction 
of the axis of the limb is unavoidably altered. 

" 3. The absolute immobility of the limb, or at least 
the inability of performing certain motions is among the 
most characteristic symptoms of dislocation. 

" 4. In dislocations with elongation of the displaced 
limb, the general and uniform tension of all the muscles 
arranged along it, gives to these organs an appearance, 
as if they lay nearer the circumference of the bone, and 
the limb were smaller than its fellow. On the contrary, 
in dislocations where the limb is shortened, the muscles 
are relaxed, but, being irritated, they contract, and ac- 
commodate themselves to the shortened state of the 
limb. Hence the extraordinary swelling of the fleshy 
part," &c. 



37 

11 5. The circumference of the joint itself presents 
alterations of form well deserving attention, and, in or- 
der to judge correctly of these symptoms, correct anat- 
omical knowledge is highly important. When the head 
of a bone articulated by enarthrosis" (a joint with a ball 
and socket) " has slipped out of the cavity, instead of 
the plumpness, which previously indicated the natural 
relaxation of parts, the head of the dislocated bone may 
be distinguished at some surrounding point of the ar- 
ticulation, while, at the articulation itself, may be re- 
marked a flatness, caused by one of the neighbouring 
muscles stretched over the articular cavity, and, more 
deeply, may be perceived, the outline and depression, 
produced by the cavity itself."* 

Such are the symptoms which Boyer and Mr. Coop- 
er consider as positive signs of dislocation. Let us 
compare them with the appearances in our patient's 
case. 

The first is " a change in the length of the limb," 
because " the articular surfaces are not at all in contact." 
This phenomenon was remarkable indeed in our patient ; 

* As it is desirable to place the general signs of dislocation in the 
most distinct point of view, I shall beg leave to make a quotation from 
the writings of a very able surgeon, and anatomist, Mr. Wilson. In 
his late lectures before the Royal College of surgeons in London, we 
find the following account of these symptoms. 

" Luxations are productive of some symptoms, which are peculiar 
to the nature of the accidents, but common to every joint affected 
by it; and of others, which must belong to the particular joints. 

" Some of the attending symptoms are not of a distinguishing nature, 
but are common to luxations, fractures, and even violent contusions. 
Among the last are the deformity and altered shape of the limb, and 
the pain felt, which is increased by any attempt at motion. 

"It is evident, that no luxation can take place, without some change 
in the form of the joint. In most cases, part of the dislocated bone 
will be felt, forming a prominence in a new situation, while a va- 
cancy will be perceived in the part from whence it was driven. But 
these alterations cannot always be detected, from the quantity of 
blood that may be immediately diffused in and around the joint, or 
from the swelling and tension, that may have subsequently taken 
place. If a cylindrical bone is luxated, the extremity farthest from 
the accident, not partaking of the swelling, will, from its position, and 



38 

the limb being longer than natural, from two to three 
inches. Had it been shortened, it might have been alleged, 
that the neck of the bone was broken, or that the socket 
was fractured, or that the muscles were contracted ; but 
it seems incredible, that an elongation so great, taken 
with the accompanying appearances, can be attributed 
to any cause, except a change of relation between the 
head of the bone and its socket, owing to the articular 
surfaces being " not at all in contact." 

the general direction of the bone, inform us of the position and situa- 
tion of the dislocated parts ; and this will be known more accurately, 
from the naturally perceptible projections of the bone, either not 
being found in their usual places, or from their being felt in other 
parts. 

" A change, in general, will be produced in the length, as well as the 
direction of the limb, and the usual motions of the joint will not take 
place, even when attempted by the hands of the surgeon. And 
should the joint have possessed rotatory motion* this will be com- 
pletely lost. It is not so in a fracture of the bone ; for motion may, 
at first, be produced by the surgeon in every direction, although cre- 
pitus, and a considerable degree of pain will attend the attempt. In- 
deed, immediately on luxation happening, if it is complete, the bone will 
admit of some motion, although this in a very short time is prevented, 
by the contraction of the muscles, which keeps the bone rigidly fixed 
in its new situation ; but all rotatory motion is generally lost from the 
first. I have, however, in a dislocation of the shoulder joint, some 
hours after the accident, found so much motion, that, had not the 
head of the os brachii been felt in the axilla, and a vacancy been per- 
ceptible under the acromion scapulae, the nature of the accident 
might have been readily mistaken. 

" A sensation not very dissimilar to crepitus will sometimes be per- 
ceived, in attempting to bend the joints of a dislocated limb, before 
much inflammation has come on, and after it has subsided, which has 
led to the supposition of the accident being a fracture. 

u When the extremity of a bone has been completely thrust from its 
socket by violence, the joint having been, previous to this, free from 
disease, the capsular ligament must always be torn. 

" Cases, however, of incomplete luxation may happen, in which both 
sets of ligaments, although stretched, shall remain free from lace- 
ration. 

" In the reduction of a luxation, the removed bone must first be 
brought to a level with the edge of its socket, and then by lateral 
pressure, or rotatory motion, returned to its cavity. 

" The difficulties that attend the reduction of a luxation, will be 
much increased by the delay, which may have taken place between 
the time of the accident's happening, and the attempt to remedy it." 



39 

The second change is in " the direction of the axis 
of the limb." This symptom was even more obvious 
than the former, the limb being permanently projected 
in front of the body, so as to form a considerable angle 
with it. The axis of the limb did not correspond with 
the axis of the body as it should do, nearly. Its direc- 
tion was such, that a line continued in the direction of 
the thigh from the knee forwards, would have struck 
the ground at some distance in front of the body. There 
was therefore a very conspicuous alteration " in the di- 
rection of the axis of the limb." 

Third, " the absolute immobility of the limb," " or 
at least the inability of performing certain movements." 
" Absolute immobility" in this instance, there was not 
indeed, but a decided " inability to perform certain 
movements," there, was; all the motions of the limb 
were diminished ; the power of extending or carrying it 
backwards, and the J motions of flexion, abduction, and 
adduction were impaired ; that of rotation hardly existed. 
On the whole, the degree of inability, though not so 
great as in some dislocations, was such as impartial per- 
sons would consider to correspond as nearly as might be, 
with the period of the accident, and the situation of the 
bone below its socket, on a part, which could not closely 
confine its motions. The unfortunate patient felt deeply 
that his locomotive powers were materially circumscrib- 
ed, and his " inability of performing certain motions," 
was a source of great unhappiness to him. 

Fourth, " In dislocations, with elongation of the dis- 
placed limb" all the muscles have a general and uniform 
tension. They appear hard as if tightly stretched. 
On the contrary, when the limb is shortened the con- 
tracted muscles swell out. There was none of the 
latter appearance, and the former was as remarkable as 
it could be, at the end of three months, during which 
all the muscles had time to accommodate themselves, 
in some measure, to their unnatural situation ; and here 
I remark that the axioms of Boyer relate to signs pre- 
senting themselves immediately on the occurrence of a 



40 

dislocation. The lapse of time will diminish the prom- 
inence of all the symptoms, of some, to a great, and of 
others, to a less degree. 

Fifth, " The circumference of the joint itself presents 
alterations of form." The hip in our case was elongat- 
ed, and the hollow caused by the falling of the trochanter 
below the socket, was so remarkable that it was no- 
ticed bj the patient himself, alarmed him, and led 
him to say to the surgeon, " Dr., explain to me the 
cause of the hollow on the outside of the injured hip ?" 
" The outline and depression of the cavity " we could 
not expect to discover in the hip-joint, after three 
months dislocation, though we might in the shoulder. 
But " the head of the dislocated bone might be distin- 
guished " with due care and attention below and behind 
its natural cavity. 

Thus we find all the positive marks of dislocation 
existing in this case. Their agreement with the symp- 
toms laid down by the best writers is in every respect 
as exact as it possibly could be, at the period of our 
examination. Will any impartial man remain in doubt 
as to the nature of this accident ? 

The symptoms of the plaintiff having been shown to 
correspond with those of a dislocated limb, it may be 
well to continue the comparison, in order to show, that 
they do not correspond with any other alleged injury 
of this part. 

From these depositions and testimonies it would ap- 
pear that it is intended to say, that the existence of cer- 
tain other injuries than dislocation, would explain the 
phenomena of this case in a more satisfactory way than 
the supposition of a dislocation ; and that the injuries 
thus supposed, or alleged to exist, are, 1st, Fracture of 
the bones of the pelvis. 2d, Contraction and relaxa- 
tion of muscles, similar to what takes place in certain 
voluntary motions, or in the hip disease. 3d, An inju- 
ry of which the precise nature is obscure. Let us then 
proceed to compare the symptoms of these injuries suc- 
cessively, with the appearances exhibited in the case of 
the plaintiff. 



41 

1. Fracture of the bones of the pelvis. — 

The consequences of a fracture of the socket, or any 
extensive fracture of the pelvis, especially such as could 
allow the thigh bone to hang down two or three inches, 
must be exceedingly formidable, and even in a large 
proportion of cases, fatal. In order to produce such 
a phenomenon, the pelvis must be crushed in pieces, 
I should conjecture, for I can only conjecture, since 
there is not, that I know of, any account of a fracture 
of the socket, accompanied with material elongation of 
the limb. On the contrary in all these accidents, the 
limb is shortened, if its length is in any way altered. 
Let us resort to the authority of Sir Astley Cooper on 
this point. 

He gives us an account of three such cases only. 
Two are minutely described, the other generally. The 
first was that of a man, on whom fell a hogshead of 
sugar. The injured limb was two inches shorter than 
the other. There was a distinct grating of the bones of 
the pelvis ; the knee and foot were turned inwards ; 
the patient died the same evening. The second had 
the appearance of a dislocation backwards ; the symp- 
toms are not related ; the patient died in four days. 
The third, very minutely described, was that of a 
woman, who had been crushed between a cart and a 
lamp -post. She lived in a very distressed state from 
the 8th to the 24th of the month. Sir Astley also 
informs us that he has known three instances of recove- 
ry from simple fracture of the os innominatum. In 
neither of these was the socket in the slightest degree 
involved, nor does Sir Astley mention any instances 
of fracture into the socket, which did not prove fatal. 

We may infer, from what is stated by this author, 
that a fracture of the socket is an accident followed by 
most violent and dangerous symptoms ; and that they 
are wholly dissimilar to those of the case of our patient. 
This will more fully appear from his general account of 
the symptoms of these fractures. " As these accidents 
are liable to be mistaken for dislocations, and as any ex- 
6 



42 

tension made for them adds extremely to the patient's 
sufferings, and is liable to produce fatal consequences, 
even if there was previously a possibility of recovery, 
I am anxious to say a few words upon them. 

" When a fracture of the os innominatum happens 
through the acetabulum, the head of the bone is drawn 
upwards, and the trochanter somewhat forwards, so that 
the leg is shortened, and the knee and foot are turned 
inwards. Such a case then may readily be mistaken for 
dislocation into the ischiatic notch. If the os innomi- 
natum is disjointed from the sacrum, and the pubes and 
ischium are broken, the limb is a slight degree short- 
er than the other ; but in this case the knee and foot 
are not turned inwards, but outwards. Of the first of 
these accidents 1 have seen two examples, of the latter 
only one. The accidents are generally to be detected 
by a crepitus being perceived on the motion of the thigh, 
if the hand be placed on the crista of the ilium ; and 
they are attended with more motion than occurs in dis- 
locations." * 

Let us compare the appearances laid down as indica- 
tions of a fracture of the socket spoken of in the depo- 
sitions, with the appearances presented in the disorder- 
ed limb of the plaintiff. 

(1.) In his case the limb was lengthened ; in fracture 
of the socket it is shortened. 

(2.) In him the axis of the limb was changed ; in 
fracture of the socket, it is not changed. 

(3.) In him the power of moving (he limb was dimin- 
ished ; in fracture of the socket, it is increased. 



* By the remark that these accidents might be mistaken for dislo- 
cation in the ischiatic notch, Sir Astley means the dislocation back- 
wards, and not that backwards and downwards ; for he expressly 
states the limb to be shortened in every instance of these ■ fractures, 
whereas in the dislocation downwards it is lengthened. Sir Astley 
lays down symptoms quite adequate to enable us to distinguish a 
fracture of the socket from a dislocation. These are a crepitus, or 
grating of the fractured pieces on each other ; a greater motion of 
the limb ; violent symptoms of inflammation about the joint, and 
finally, very distressing effects on the whole body, and even a fata! 
termination. 



4S 

(4.) In the plaintiff, the muscles were elongated and 
tense ; in fracture of the socket, they are shortened and 
relaxed. 

(5.) The form of the hip is changed in both cases, but 
in a dislocation downwards, it is longer and narrower, 
and was so in him ; whereas in fracture of the socket, 
it is shorter and rounder. 

(6.) In this case there was no grating of the fractured 
pieces of bone on each other, or crepitus ; in fracture 
of the socket, this symptom is most remarkable. 

(7.) The effects of this injury were not very violent 
and alarming, the patient was at no time in danger of 
losing his life ; in fracture of the socket, on the contra- 
ry, the consequences are very severe, and, in the great- 
er number of instances, even fatal. 

Possibly it may be alleged, that I have assumed for 
the parallel the existence of the worst case of this inju- 
ry, and that if, instead of it, I had taken one of the in- 
stances of fracture of the os innominatum, which ter- 
minated favourably, the resemblance between the two 
cases would have been greater. A little reflection only 
is required to see, that a fracture of the os ilium across 
its superior part, or a fracture of the parts of either of 
the other bones, out of the socket, w T ould not for a mo- 
ment be suspected as a cause of the phenomena in our 
case. To afford grounds for the supposition of elonga- 
tion of the limb being caused by injury of the bones of 
the pelvis, this injury must not only be presumed to 
extend through the socket, but moreover there must be 
together with a fracture of the socket, a very extensive 
separation of the broken parts, a corresponding rupture 
of ligaments and an extensive laceration of the super- 
jacent muscles. Such must be the state of things sup- 
posed to exist in an injury, which should be adequate 
to the explanation of the appearances in this case. I 
say, supposed to exist, for I am not informed that there 
is any such case on record ; nor do I believe that 
such an occurrence as a fracture sufficient to give three 
inches' increased length to a limb, could consist with 
the patient's life for a single hour. 



44 

From the comparison made above, it seems there is 
no great similarity between the symptoms of this case, 
and those consequent on any known, or supposable in- 
jury of the bones of the pelvis. 

2. Contraction and relaxation of the muscles. The 
words are these : " As for the apparent lengthening of 
the affected limb, I think that is owing to the preter- 
natural contraction and relaxation of the muscles situat- 
ed about the hips ; and is made to appear so by the 
twisting of the bones of the pelvis on the spine. Any 
person, when sitting on a chair, can by an exertion of 
the muscles make one knee project beyond the other, 
as much as Lowell's did when I saw him. The 
same lengthening of the limb takes place in a disease 
of the hip, called the hip disease, where no external 
violence has been received." There seems to be a 
slight incongruity between these two statements ; for it 
is first said that the apparent lengthening of this limb is 
owing to the contraction and relaxation of the muscles ; 
which we must suppose lo have been brought on by the 
violence done to the part ; but afterwards that the same 
lengthening may take place in a perfectly sound state 
of the bones ; and in the disease of the hip, without ex- 
ternal violence. To which of these causes is it intend- 
ed to attribute this appearance ? As the nature of the 
investigation in which we are engaged, compels me to 
consider, not only alleged, but also supposed cases ; it 
becomes necessary to make three separate questions ; 
and to examine, 1st, whether the elongation and other 
phenomena were caused by a contraction and relaxa- 
tion of muscles, consequent on violence ; 2dly, whether 
this contraction and relaxation might not be a volunta- 
ry exertion ; 3d, whether it might not be the result 
of a complaint similar to the hip disease. 

First, a contraction of muscles is a frequent conse- 
quence of a wound, such as is made in puncturing 
a part with a nail, a needle, and sometimes a lancet ; 
but as an effect of a bruise or contusion, it is a rare 
occurrence. A contraction brought on by a bruise, 



45 

could take place only from extraordinary violence, 
contusing or breaking down the texture of the muscles, 
and thus producing inflammation, with its concomitant 
phenomena, and a subsequent rigidity from effusion of 
coagulated lymph, into the interstices of the muscular 
fibres. 

In the case of the plaintiff the violence was not 
greater than we daily hear of from the overturning of 
stage-coaches and other carriages. In the second place, 
this violence was not inflicted directly on the hip, but 
on the back and thighs ; and in the third place, the con- 
sequent symptoms were not such as to lead to any sus- 
picion of severe muscular inflammation. We have not 
therefore any good reason for attributing the contraction 
to the direct effects of the accident. If we suppose a 
case of contraction actually following a violent injury, 
the train of events would proceed something in this way. 
The patient being thrown from his horse, falling directly 
on the hip, would, notwithstanding the great violence, 
find himself able to stand and walk at first. Soon 
after, the hip would swell and inflame, with much af- 
fection of the whole constitution. When the inflamma- 
tory symptoms had subsided, the muscles about the hip 
would be found contracted and indurated. The con- 
traction would increase, and draw the limb more and 
more toward the body ; soon the limb would waste 
away, and its power of motion gradually diminish, till 
the part became wholly, or in a great measure, useless. 
Such was not the history of bur patient. Immediately 
on his falling he found himself maimed ; his power of 
walking was at an end, the limb was at once distorted, 
and this to so great an extent, that he immediately 
desired surgical aid, to set it in order ; afterwards he 
lay 15 or 16 days without extraordinary swelling, or 
other marks of inflammation. When he began to use 
the limb, its motions were limited, and difficult ; but 
since, they have been regularly increasing, as always 
happens in old dislocations from the formation of an 
artificial socket. 



46 

Let us in the next place, consider this contraction and 
relaxation of muscles, as an effect of voluntary exertion : 

M Any person sitting in a chair, can, by an exertion 
of the muscles, make one knee project beyond the other, 
as much as Lowell's did when I saw him." 

This remark is ingenious and true. When in the sit- 
ting posture, the bone of the opposite side may be made 
a pivot, whereon to turn the pelvis, which may be twist- 
ed and lowered, and the limb of the side protruded, by 
the aid of a constant and considerable effort. But, if 
the posture of the body be changed from sitting to up- 
right, this kind of distortion vanishes, and it is not pos- 
sible to continue the protrusion. Had such been the 
cause of the plaintiff's appearance, it would have been 
easy to have detected the fallacy, by examining him in 
different positions, and especially by causing him to 
waik, and thus rest the weight of the body on the dis- 
ordered part. His difficulty continued the same, how- 
ever, in all situations, and under all circumstances. 
Whether he was sitting, lying, standing, or walking ; 
when his mind was occupied with other subjects ; when 
he was submitted to the action of cords and pullies, and 
of manual force ; when he was in his ordinary condition 
of health, as well as when reduced by the relaxing 
power of bleeding, and other debilitating causes ; — under 
all these circumstances, the disordered limb remained 
much too long. 

Lastly, we are to inquire, whether the supposed con- 
traction and relaxation of muscles could be the effect 
of a complaint like the hip disease ? That there is 
some degree of similarity between the appearances in 
this case, and those of the hip disease, must be admit- 
ted ; but the resemblance fails in too many important 
and essential particulars, to allow us to confound the 
two with each other, or to authorize us to consider them 
as arising from an identical cause. The hip disease is 
preceded by a bad state of the constitution, and the first 
remarkable occurrence is a sort of limping gait, with a 
propensity to stumble, if the patient be a child, and an ap- 



47 

parent weakness of the limb. This is followed by a 
pain in the knee, or rather in the thigh, a little above the 
knee ; the limb wastes, becomes flaccid, and seems to 
lengthen a little. In moving the thigh bone in its socket, 
there is usually much pain. As the disease advances, the 
limb grows shorter, for it quits its socket, and is ulti- 
mately drawn up to the extent of a number of inches, 
the thigh being bent forward. The joint suppurates ; 
matter is discharged through one or more apertures ; 
and ultimately pieces of bone are separated, and expelled 
through the wounds.* 

The history of this disease shows that it has not any 

* It may be thought necessary to advance the authority of some 
author, to afford a more fair comparison of symptoms ; and I there- 
fore quote from Mr. Ford, who is considered a standard writer on 
this disease. " The caries of the hip joint, always painful in its con- 
sequences, and sometimes fatal in its event, steals on at first so imper- 
ceptibly, and arrests the attention so little, that it is scarcely consid- 
ered as a serious disease. The constitution is not at first materially 
affected by it ; paleness of countenance, fits of languor and heaviness, 
succeeded by a proportional flow of spirits, and sudden exertions, are 
accidents so common in the lives of young persons, that they pass for 
commou circumstances, and attract but little attention. There are, 
however, symptoms often accompanying the first pathognomic marks 
of this disease, which are, a sort of limping gait, lameness scarcely 
discernible, and a weakness of the leg and thigh just beginning to be 
apparent. 

" About this time, the limb, on strict examination, will be found, 
both in the thigh, and on the calf of the leg, to be really lessened in 
its circumference. A striking alteration likewise takes place with 
regard to its length. It is more or less elongated, the elongation is 
visible, and the degree of it ascertainable. Let the patient be placed 
in a horizontal position, with both his legs extended properly, for a 
comparison with each other ; the patella, with the condyles of the 
thigh bone, will appear in the diseased limb, manifestly lower than 
the same bones on the sound side. It may be still farther ascertain- 
ed by an inspection and comparison of the relative situations of the 
great trochanter, or the internal malleolar process of the tibia, with 
the corresponding parts of the sound limb. On viewing attentively 
the patient in an erect posture, it is clearly discernible, that there is 
on the diseased side, an alteration with respect to the natural fulness 
and convexity of the nates, that part appearing flattened, which is 
usually most prominent ; and a little below, towards the thigh, there 
is a degree of swelling different from, and strongly contrasted to, the 
natural appearances of the sound limb." x 



48 

similarity to that of the plaintiff, excepting in the elon- 
gation and flexion of the limb. The former symptom 
is slight, compared to what happened in him, and is only 
apparent,* since the lengthening actually arises from the 
descent of the pelvis on the lame side. 

In Mr. Lowell's case, the elongation of the limb 
was not only apparent but real ; and in degree far ex- 
ceeding what is known in any case of hip disease. The 
knee projected beyond the other, in a manner perfectly 
obvious, and to an extent by measurement, of about 
three inches. . The concomitant circumstances were 
quite different from those of a diseased hip. He had 
no marks of inflammation, except, as we are told, 
for a few days after the accident, during which, the 
usual swelling and pain of a dislocation were seen to 
exist. When he recovered from its first effects, and 
from that time to the present, he has been as free from 
the signs of inflammation, as a man with a thigh bone 
out of its socket could well be. He had no pain 
nor distress on the limb being moved in any direction, 
no uneasiness on putting it to the ground. The pelvis 

# The cause of the fallacious appearance of elongation in the hip 
case, has not been understood till of late years, and even now does 
not seem to be generally adverted to by practitioners of su gery. 
Mr. Crowther, in his treatise on white swelling, having obtained the 
hint from Mr. John Hunter, first placed this matter in a distinct 
light. According to him there is no real lengthening of the limb in 
the hip case, but the apparent lengthening is owing to the inclination 
of the pelvis to the lame side, in consequence of which the limb de- 
scends lower than before ; so that even when the patient is placed 
on his back, and in bed, the disordered limb seems longer than the 
other. The obliquity of the pelvis in this case, is, in the opinion of 
Mr. Crowther to be ascribed to the patient's endeavouring to throw 
the weight of the body on the sound side. The cavity of the joint 
being diseased and tender, he is unwilling to rest the weight of the 
body on that side ; and when he does so he does it with a bent limb, 
in order that the head of the thigh bone should not press so directly 
into the diseased socket. Formerly it was thought that the limb was 
pushed down by collections of fluids in the joint, by relaxation of the 
ligaments and other causes. If however, the limb is measured from 
the joint to the heel, its length will be found to be the same as that 
of the other side. 



49 

was not more inclined than must happen in a dislocation 
downwards. The muscles put on the strain tend to 
approximate their two points of attachment ; hence it 
must happen that in a dislocation downwards and back- 
wards, ihe Psoas and Iliacus, the Pectineus, and espe- 
cially the fore part of the Gluteus medius will pull the 
pelvis downwards, unless the head of the thigh bone is 
so wedged against it, as to prop it up. On the whole, 
it may be inferred, that there is little similarity in this 
to a scrophulous hip case, and, of course, the causes ap- 
plied to explain the elongation of the limb in the latter, 
will not do it in the former. 

The flexion of the limb considered alone, is not very 
important as a discriminating symptom, because it is 
found to accompany many disorders of the limb, yet we 
must notice that in few of them is the degree of con- 
traction so great as in this dislocation. 

In the remarks made above, the phraseology employ- 
ed has not been adverted to, but it is now necessary to 
state that the terms in which this proposition is laid 
down, are objectionable. Namely, that the apparent 
lengthening of the affected limb, " is owing to the 
preternatural contraction and relaxation of the muscles 
about the hips." Physiologists would admit, I suppose, 
that a relaxation of muscles might allow a disordered limb 
to become longer, and that a contraction of muscles would 
shorten it. Then if to lengthen a limb the muscles must 
be relaxed, such should have been the condiiion of these 
organs in our case ; that is, the muscles about the hip 
must have been relaxed. But if these muscles had been 
relaxed, the limb would have been suspended from the. 
body, all the joints being straightened, like those of a 
paralytic, which was not the case ; for, instead of 
hanging down, it was actively and permanently drawn 
forwards towards the body. Whence it follows, that 
the complaint could not have been simple relaxation. 

Now take the case of contraction. If any one mus- 
cle were preternaturally contracted, it would undoubted- 
ly shorten the limb, although the other muscles were 
7 



50 

relaxed ; a contraction of the Biceps, bends the arm, a 
contraction of the Tibialis draws up the foot, and a con- 
traction of the Psoas magnus would shorten the lower 
extremity. Thus it follows, that an elongated limb 
cannot coexist with a preternatural contraction of mus- 
cles ; but the plaintiff's limb was elongated, and of con- 
sequence his affection could not have arisen from a pre- 
ternatural contraction of the muscles. 

3. An injury of which the precise nature is obscure. 

u It is difficult to determine," says the deponent A., 
" in the case of injuries of the hip, precisely what the 
injury of the bones is ; but it has frequently happened 
within my knowledge, that by a fall directly on the hip 
joint, though the bone was not dislocated, as was evi- 
dent by the natural position of the foot and limb gene- 
rally, and from its being moved by the hand of the sur- 
geon in all directions, yet the patient has never recover- 
ed from his lameness, and in several instances, they 
have never been able to walk afterwards." The object 
of these remarks is, I suppose, to intimate the suspicion, 
that Mr. Lowell's case might be one of these obscure 
injuries of the hip, in which it is difficult to determine 
" precisely what the injury of the bone is." Though to 
compare the known with the unknown, is the province 
of mathematics, and cannot be expected of surgery, it 
will not, I think, be impossible to show, first, that the 
real nature of these cases may be discovered by careful 
investigation ; and second, that the case of Mr. Lowell 
is evidently different from these. 

To this kind of accident, I would then ask the atten- 
tion of surgical practitioners. It usually occurs in aged 
persons, from a fall directly on the trochanter. The 
patient, after the occurrence of the accident, finds him- 
self lamed, and the hip painful. On moving the limb, 
great pain is produced in the joint, and often a spas- 
modic affection of the muscles, which in some instances 
manifests itself also when the limb is not moved. The 
circumstances most to be noted, are, that the limb is 
neither shortened nor turned out, nor is there any grat- 



51 

ing of the bones ; yet the patient does not at all recover 
from the lameness ; on the contrary, it for some time 
increases. Ultimately indeed, the foot turns out, and 
the limb shortens slowly. The patient never regains 
the natural use of the limb. 

Is not this accident a fracture of the neck of the thigh 
bone, within the capsular ligament ? But why does not 
the limb become shorter, and the foot turn out, and the 
fractured bones grate, as usual in such cases ? Because, 
we answer, the capsular ligament is not torn. Therefore, 
the limb cannot at first become shorter, nor can the foot 
turn out materially, nor the broken pieces move on each 
other to cause a grating.* 

* When the grating has been ascertained, and its situation distin- 
guished, there can be no doubt of the existence of fracture of the 
neck of the thigh bone, even though the shortening of the limb, and 
other concomitant circumstances, should not present themselves ; but 
I beg leave to say that I have known instances of fall on the trochanter, 
in which the grating could not be distinguished, yet a permanent lame- 
ness and shrinking of the limb occurred Can there be a reasonable 
doubt as to the nature of these cases ? if they are not fractures of the 
neck of the thigh bone, what are they ? They cannot be caused by a 
rupture of the inter-articular ligament. A fracture of the socket is at- 
tended with symptoms incomparably more violent. No one will con- 
sider them as the phenomena of dislocation. They must, I think, be 
fairly considered as fractures of the neck of the thigh bone, though 
not accompanied with the most common symptoms of that accident. 
In a long and interesting conversation on surgical subjects, which I 
had last summer with a gentleman, whose genius and practical skill 
do honour to this country, as they would to any other, and of whose 
character I cannot sufficiently express my respect, I mean Dr. Phy- 
sick, of Philadelphia ; I stated to him the general appearances in 
such injuries of the hip, for the purpose of eliciting his opinion ; not 
referring to the plaintiff's dislocation, which was not in my mind at 
the time. Dr. Physick promptly replied, (my much valued friend, 
Dr. Horner, the anatomist, being present,) that they were undoubt- 
edly instances of fracture within the capsular ligament of the hip joint. 

The controversy between the English and French surgeons, in re- 
gard to the possibility of a union in the fracture of the neck of the 
os femoris is well known ; and to those who have attentively read 
what Sir Astley Cooper has written, it will apeear to be a point, 
settled, that true fractures of the neck of the thigh bone, within the 
capsular ligament do never unite. In Richerand's late work, there 



52 

The shortening takes place afterwards, from the con- 
traction of muscles, and the gradual absorption or 
wasting of the ligament. 

When the capsule is torn through at the time of the 
fracture, the ordinary phenomena of shortening, &c. 
present themselves at first. 

I may venture to say then, that, whenever these ob- 
scure injuries are followed by the alleged effects, that is, 
by a permanent lameness, or an inability ever to walk 
afterwards, they are truly cases of fracture of the neck 
of the thigh bone. Then, if we make any other com- 
parison, it must be with the signs of this accident, and 
we may compare the symptoms of our case with frac- 
ture of the neck of the thigh bone with the usual symp- 
toms, with fracture of the neck of the thigh bone with 
unusual symptoms, and with fracture of the neck of the 
thigh bone without distinct symptoms. 

In the first case, namely, the fracture of the neck of 
the thigh bone with the usual symptoms, every surgeon 
knows that the limb is shortened, the foot is remarkably 
turned out, and the broken bones produce a grating. 
This is quite different from the plaintiff's case. 

In the second, or fracture with unusual symptoms, the 
foot is turned in, the limb is shortened, though slightly, 
the crepitus, or grating, may be felt.* This case will 

is a curious passage relating to this dispute, which shows that he is 
not willing to adopt the opinion of Sir Astley on this point, though 
he praises him on others. " Such persevering researches," says 
Kicherand, " to attain the best means of treating fractures of the 
neck of the femur would have been puerile, if, as Sir A. Cooper has 
said in a recent work, these fractures were not susceptible of consoli- 
dation. How shall we explain so strange an assertion of this cele- 
brated English surgeon, who reads little, it is true, but might have 
seen in all anatomical museums, whole ossuaries of fracture of the 
neck of the thigh bone consolidated perfectly, or partially." 

* This peculiar turning in of the thigh, in certain instances, has 
been said to be owing to the fracture being on the outside of the in- 
sertions of the muscles rotating outwards ; so that they lose their con- 
trol of the limb, while some of the inward rotators are still attached 
to the bone, and must of course draw the limb inwards. 






53 

not, I suppose, be thought to resemble that of Mr. 
Lowell's. 

The third is, when there are no symptoms of a dis- 
tinct character, and this seems to be the case more es- 
pecially alluded to in the deposition. If there are no 
symptoms attendant on the accident, and none afterwards, 
the case is very different from ours, in which the symptoms 
are strongly marked. And again, if, though there were no 
symptoms immediately following the accident, yet some 
presented themselves at a subsequent period, they would 
always, in a case of permanent lameness, be accompa- 
nied, as already shown, with more or less shortening of 
the limb, which is the state opposite to that of the 
plaintiff. 

We might suppose any other possible injury of this 
part, as, for example, injury of the orbicular or the in- 
ternal ligament, inflammation of the synovial membrane 
of the joint, contusions of the muscles, or tendons ; and 
show in a satisfactory manner, I apprehend, by com- 
paring the symptoms, that none of them resemble the 
strongly marked characteristics of the plaintiff's injury. 

Thus it seems, that a comparison of the features of 
this, with those of the various affections of the hip joint, 
presents no accordance of the former with those of any 
known or supposed injury of this part, except a dis- 
placement of the limb in a direction downwards, or be- 
low its socket ; and I may add that, out of nine cases 
of dislocation of the thigh from violence, which have 
fallen under my notice, no one has exhibited more dis- 
tinct marks than this, of a change of relation between 
the head of the bone and its natural cavity. 



54 

Some individuals may be disposed to believe, that the 
direct testimony of professional men would be more 
satisfactory than any argumentative discussion of the 
merits of a case not easy to comprehend, without be- 
stowing on it more time and attention than they are 
willing to give. They ask for the opinion of competent 
and impartial judges, who have had an opportunity of 
actual examination of the disordered parts. Unnecessa- 
ry as the more direct application of this test may seem, 
I cannot decline aoy mode of trying the question, which 
appears calculated to dissipate the obscurity that has 
gathered over it. 

From the account we have already given, it appears, 
that the medical gentlemen who examined, or were 
supposed to have examined, this case, delivered opinions 
absolutely opposed to each other. In order to form a 
just estimate of these clashing judgments, we must con- 
sider the number of individuals on each side, together 
with their capacity and opportunity for judging, and 
the degree of impartiality, with which they might be 
supposed to view the facts. 

Four medical practitioners have deposed or testified, 
that the symptoms did not arise from dislocation, but 
from injury of the pelvis, or some other cause. 

The first of these four is the deponent A. The tes- 
timony of this deponent should be considered very im- 
portant, in what relates, to experience in surgery, and 
knowledge of anatomy. On the other hand it must be 
noticed, that he does not speak of having seen more 
than one case of hip dislocation, so that his experience, 
on this subject, loses some of its weight. Then as to 
the period of examination, it will be recollected, that 
he did not see the patient till nine months after the ac- 
cident, when considerable changes of appearance must 
necessarily have occurred. Further, that he examined 
once, and once only. 

The second deponent is the gentleman who was 
present at the examination of the deponent A. His 
deposition is evidently grounded on the opinion of the 



55 

other, and must be considered as adding little if any 
weight to it. 

The third and fourth practitioners on this side, never 
examined the patient. They founded their opinion on 
observations not stated, but which may be presumed to 
have been drawn from a cursory sight of the plaintiff in 
the court house, at a distance of time not very far from 
three years from that of his injury. They could not 
therefore be expected to be very good judges of his dif- 
ficulty. 

From this view it appears that only one of the four 
actually examined for himself, and it must follow that 
we cannot admit the testimony of more than one indi- 
vidual as affording any direct support to the negative 
opinion, that this bone was not displaced. 
Let us next consider the positive testimony. 
In presenting the evidence in favour of the dislocation^ 
I am compelled to place my own before that of my col- 
leagues. Not that I would wish to have it considered 
as of more weight than that of other gentlemen, but 
because my opinion was formed and given before theirs ; 
and if it were an erroneous one, I should desire to take 
the imputation from them to myself. The comparison 
I wish to make will relate to two points : first, the epoch 
of the examination ; second, the extent or degree of this 
examination. 

As to the first point, the epoch of examination, it has 
been already stated, that I examined the patient three 
months from the occurrence of his accident, soon after 
he had begun to move about from his confinement, 
while he was still on crutches, and before he had made 
any great use of his limb. The deponent did not ex- 
amine till nine months from the accident, six months 
after my examination, when the patient had learnt to 
use his limb considerably, and when, of course, all its- 
appearances must have undergone material alterations. 
Secondly, as to the extent of the examination. When 
the patient was first subjected to my inspection, I 
adopted various modes of satisfying myself what his in- 



56 

jury was, but I would not decide definitively at once. 
I took time to examine the matter, looked into Sir 
Astley Cooper's book, and obtained all the informa- 
tion I could ; then I examined the patient a second time, 
put him into various positions, examined the prominen- 
ces of the bones ; gave his limb all the motions it would 
receive, and then made up my judgment After this I 
had a third and a more full opportunity of exploring the 
nature of the case ; he was placed on a table, and 
operated on for a reduction of the limb, between one 
and two hours. During this time the limb was moved 
in various directions, the prominences and depressions of 
bones felt and indicated to gentlemen around, and by 
some among these, the head of the bone itself was felt, 
or supposed to be felt, and pointed out. The deponent 
A., on the other hand, made but a single examination, 
and that in the presence of only one medical person, so 
far as we are told ; this examination was never repeated. 
Tht testimony next to be considered on this side, is 
that of the consulting physicians and surgeons of the 
Massachusetts General Hospital ; namely, Drs. David 
Town send, Thomas Welsh, James Mann, and Wil- 
liam Spooner. The patient, after having been con- 
veyed to the Hospital, was submitted to the inspection 
of these gentlemen. They wpre desired to examine 
whether the bone were dislocated or not, and to consider 
whether, if so, any attempt to reduce it were justifiable. 
They deliberately made their examinations, and pro- 
nounced that a dislocation did exist. As to the reduc- 
tion, they were all of opinion it could not be effected, 
but thought if the patient insisted on it, that it would 
be justifiable to give him the trial. This trial was made 
before them, they had opportunity of again seeing and 
examining ; they did examine repeatedly and constantly 
through the whole operation ; and, though " the bone 
was not reduced," they did not the less believe it was 
out of place, and I presume they continue to believe it 
unto this day. 



57 

Perhaps it will be said that these gentlemen were in~ 
fluenced by the judgment I had already given, or that 
they were unwilling, through delicacy, to make any op- 
position to it. In reply to such remarks, I must say, 
that they have always been in the habit of very free 
discussion with me, on doubtful questions in the Hos- 
pital, and from these discussions I have often received 
much light, and the patients much advantage. My 
habits of intercourse with most of these gentlemen have 
not been sufficiently close to give me the means of 
operating on them through the medium of private friend- 
ship, since with some I have not exchanged a word for 
years excepting at these consultations. They are none 
of them of an age to be swayed by me, contrary to their 
own judgment, and have had experience enough to 
enable them to make up their minds on cases like this 
with perfect independence.* 

* These physicians are in truth as venerable for age as they are for 
experience, and public service ; and I cannot but regret, and I trust 
every man of character who reads this trial will also regret, that 
the attorney for the defendant should have indulged himself so freely 
in expressions derogatory to the reputation and injurious to the feel- 
ings of such gentlemen. In order to remove the unfavourable im- 
pressions which the course pursued by him may have made in regard 
to them, I shall take the liberty to state who they are. 

Let it be remembered that the consulting physicians at the Hos- 
pital, in the part they took in this case, were performing a public and 
a gratuitous service ; moreover, that the patient and his surgeon, the 
plaintiff and defendant, were utterly unknown to them. — Three of 
these gentlemen were surgeons in the army of the revolution. Dr. 
Townsend, the friend of the late governor of this state, was in the 
American army during the whole of the war of Independence, and 
for the last eighteen years, has been surgeon of the Marine Hospital 
of this department, where he must have had great opportunities for 
surgical experience. Dr. Welsh was also surgeon in the American 
army, and has been for a great number of years, health physician of 
the port of Boston, has held many honourable offices in the profession, 
and among others that of Vice President of the State Medical Society. 
Dr. Mann was also surgeon during the whole revolutionary war, and 
held a distinguished surgical rank in the last war with Great Britain, 
and does so at this time. He is very honourably known as the author 
of a valuable treatise on the Cholera of infants, of Medical Sketches of 
the late war, and other meritorious publications. Pr. Spooner is an 

8 



58 

Let me repeat that the four consulting physicians 
above named, saw this case three months after the inju- 
ry ; they had most of them seen dislocations of this 
kind, and on a full examination of the disordered part, 
were unanimously of opinion that the bone was out of 
joint. Compare their judgments, thus formed, with that 
of the deponent B., who was present at an examination ; 
and with that of the witnesses C, and D., who never 
examined, nor were even present at any examination. 

The affirmative testimony is not finished. The his- 
tory of the case already given, shows that the plaintiff 
afterwards applied to a very experienced practitioner of 
surgery, who was so satisfied of the existence of a dis- 
location, as to proceed, in company with other practi- 
tioners and students to attempt the reduction of the 
limb by the most thorough and strenuous efforts. This 
was a short time after the trial at the Hospital. 

In fourteen days more, the persevering plaintiff was 
induced to apply to one celebrated for his practical skill 
in reducing bones. He also made an attempt to reduce 
the dislocation, and of course we have the strongest 
reason to presume he believed in its existence. 

Edinburgh graduate, of about 1783, a gentleman distinguished for his 
frank and independent character, and from whose sentiments I take 
pleasure in saying I have derived particular benefit in the Hospital. 

Are the names of such persons proper subjects for the jeers of a 
lawyer, to be thrown out in a court of justice, and afterwards dis- 
tributed through the country ? and would the strength of the argu- 
ment have been weakened by the omission of witticisms on the 
characters of these individuals ? 

Whatever may have been the prejudices existing in the minds of 
the court and the jury, I think I may venture to say, that if at the 
time of this affair it had been necessary to select four gentlemen 
qualified by their general reputation and their experience to judge in 
this case, no other four practitioners could have been more properly 
chosen from the state of Massachusetts ; — I may go farther, and say, 
from the whole of this section of the country. 

Respectable as they are, and laborious as have been their services, 
they are not, as the attorney tells us, when he would excite sympathy 
for his client, " nursed in the lap of ease." Every one of these gen- 
tlemen, after a life of severe public and private duties, is still called 
on to exert himself in an honourable slavery to the labours of his 
office and profession. 



59 

The whole of this mass of opinion in favour of the 
existence of a dislocation, was formed on examinations 
which took place about three months only from the time 
of the accident.* When this fact is duly considered, and 
when in connexion with it we regard the number of 
those who examined, the nature of the examination they 
made, their respective ability to form a solid judg- 
ment, it must I think be admitted, that it would be dif- 
ficult to have a greater weight of testimony as to any 
fact of this description ; and that on the other side, the 
negative evidence of the deponent A., with the addition 
of that of the deponent B., founded on an examination 
six months later, must be viewed rather as a contrast 
to the affirmative, than a refutation of it. 

We have something still to add. The plaintiff, after 
the third attempt made on him, quitted Boston to return 
to his own state. On his way home, it appears that he 
took the advice of Dr. Benjamin Brown, of Waldoboro, 
in the state of Maine, a practitioner of great experience 
and respectability. His opinion as expressed in his de- 
position was, that the " plaintiff's inability or lameness 
is a simple luxation of the head of the thigh bone, and 
that with skilful treatment and prudent management at 
the time of recent injury," " the plaintiff might now 
have the use of his limbs. "f 

* Jt might be thought I should adduce the practice of the defend- 
ants in support of the opinion that the limb was actually dislocated at 
first, contrary to what appears to have been the notion of the depo- 
nent A. On the other hand, it might with equal truth be said, that 
their subsequent practice is opposed to the doctrine of a dislocation 
existing at present. What degree of weight is to be attached to eith- 
er, I do not think it necessary to inquire at present. It is sufficient 
perhaps to show I have not forgotten that these gentlemen did make 
an examination of the case ; though not after it became a subject of 
litigation. 

t On this very distinct and positive testimony, the defendant's at- 
torney has commented, with many sarcastic expressions. — The testi- 
mony is, however, really of much weight. Dr. Brown was called to see 
the patient by himself ; he had experience on the particular subject in 
question, since it seems he was " in the medical and surgical depart- 
ment of the United States during the term of five years, during which," 



60 

Finally, we have the testimony of Dr. Estabrook, to 
deprive us of a supposition which otherwise might have 
been entertained. Sir Astley Cooper relates, as we 
have seen, the case of a man, who having a dislocated 
hip, was subjected to the skill of many surgeons with- 
out success, and at last, after a lapse of years, was 
suddenly cured by the bone slipping spontaneously into 
its socket. Some ingenious persons might think it 
proper to intimate, that during the six months between 
our examination and that of the deponent A, the plain- 
tiff's bone might have returned into its socket in a 
similar manner. But Dr. Estabrook deposes, that 
" Jan. 23, 1822 [1823], he examined Lowell's hip 
and found it dislocated ; the head of the bone was out 
of the socket ; with skilful treatment he might have 
recovered the use of the hip." The examination and 
opinion of this gentleman was as independent of ours in 
its circumstances as it was distant in time. None of 
us, to my knowledge, communicated with either of the 
physicians of Maine, whose depositions are here given. 

This testimony is too forcible to require any rhetoric 
to display it. There is however one more fact to add 
to its weight. The patient still lives ; still carries 
about with him the signs of his injury, obvious to every 
beholder ; and although the gradual formation of an 
artificial socket will diminish his trouble, and obscure 
his symptoms, he must have an elongated and distorted 
limb while he lives. 



says he, " I was in the land and sea service in the revolutionary war ; 
I have been in several engagements both on the sea and on the land, 
in which T have performed many surgical operations. I have seen and 
reduced several dislocations of the head of the os femoris or thigh 
bone." So far as I can learn, there is not in the state of Maine a medi- 
cal gentleman more distinguished for professional experience and in- 
tegrity of character than Dr. Brown. 



61 

Having thus concluded my remarks concerning the 
first of the two propositions laid down above, viz. that 
no dislocation existed in the case of Mr. Lowell, and 
having as I trust made it sufficiently evident that a dis- 
location did exist, I would now state that this is really 
the essential point to be proved. As to the particular 
species of dislocation, it is much less important that the 
profession or the public should agree with me in opin- 
ion. In the trial, however, it happened, that the de- 
fendant's attorney, availing himself of some extracts 
from the work of Sir Astley Cooper on dislocation, 
made it appear, that in the opinion of this author, no 
such species of dislocation could exist, as that I had 
assigned. Whence the court and jury were made to 
believe, that, if we had been in error as to the kind 
of dislocation, we might have been so even as to the 
existence of any dislocation. Had those who examin- 
ed the case, been present as witnesses in a court of 
justice, it would not have been difficult for them to 
have made it appear, that the two questions might and 
ought to have been separated from each other. As 
the matter actually stands, I am called on to show 
more precisely the grounds on which I formed my opin- 
ion of the particular kind of displacement ; and this 
appears to be the more necessary, because the attorney 
has employed, in regard to this opinion, terms applicable 
to the most gross ignorance of surgery and anatomy. 
" The account given by Dr. Warren," he says " will 
prove to be a complete fallacy," " a most egregious 
error." " Its refutation will be established on the most 
obvious principles of anatomy, which, it will appear, 
have not only been disregarded by these learned doc- 
tors, but that their conclusion has been adopted in 
absolute defiance of them." Let us again enquire 
whether this language is authorized by facts. 

In order rightly to comprehend the case, it is neces- 
sary to attend to the distinctions between the different 
kinds of dislocations of the the thigh bone, or os femo- 
ris, on the hip bone, or os innominatum ; and to under- 



62 

stand the nature of these distinctions we must have 
some acquaintance with the form of the bone principally 
concerned in them. 

This is called os innominatum. It is a large flat 
bone spreading out above, and contracted below. To- 
wards the lower part is seen that deep excavation, or 
socket, called acetabulum, which receives the head of 
the thigh bone. To render its anatomy more intelligi- 
ble to those not versed in anatomical studies, I have 
annexed a representation of it, with indications of the 
parts most connected with the questions to be discussed. 

Plate I. 

A lateral view of the os innominatum of the left side, 
reduced about one third from the natural size of this 
bone in an adult ; the acetabulum being placed on a 
level with the eve. 

A. The acetabulum. 

B. The posterior, inferior, spinous process of the ilium. 

C. The tuberosity of the ischium. 

D. The foramen ovale. 

E. Anterior extremity of the pubes. 

F. Spinous process of the ischium. 

m. A line denoting the situation of the ligament, which 
extends from the tuberosity of the ischium, to the 
posterior, inferior, spinous process of the ilium, form- 
ing the posterior boundary of the ischiatic notch. 

hb. A line denoting the situation of the ligament which 
passes from the spinous process of the ischium, to 
the side of the os sacrum, dividing the ischiatic notch 
into two unequal parts. 

ecc. Three lines marking those parts of the os innom- 
inatum where the ilium, ischium, and pubes are con- 
nected by cartilage, before their ossification is effected. 

dd. A circle marking that part of the bone, on which 
the head of the femur rests when it is dislocated 
backwards and upwards on the Dorsum ilii. 

ee. A circle marking the situation of the head of the 
femur, when dislocated backwards to the superior 
part of the ischiatic notch. 



63 

ff. A circle marking the situation of the head of the 
femur, in a dislocation backwards and doivnwards 
on the inferior, part of the ischiatic notch, and os is- 
chium. 
gg. A circle showing the situation of the head of the 
femur, when dislocated forwards and upwards, on the 
os pubis. 
hh. A circle showing the situation of the head of the 
bone, in a dislocation forwards and downwards, on 
the foramen ovale. 

In this view the bone appears as one, and is actually 
so in the full grown body, but in the earlier periods of 
life it consists of three separate bones, w 7 hose connec- 
tion is formed by cartilage. The three bones are called 
ilium, ischium, and pubes ; they meet together in the 
socket; The ilium is the uppermost and broadest ; 
rounded at the top, and gradually contracting below. The 
ischium is the lowest of the three, and has the let- 
ters C, and F, in the plate. The pubes is the anterior, 
or front bone, and has at its extreme part, the letter 
E. In order more distinctly to indicate the extent and 
bounds of each of these bones, three straight lines have 
been drawn from without to the interior of the socket, 
each marked c. The part above the two superior lines, 
is ilium ; that below the right hand line, ischium ; and 
that below the left hand line, pubes. The three bones, 
uniting, form the socket. When the human body ap- 
proaches the adult age these bones coalesce, or co- 
ossify into one, called the os innominatum. The broad 
upper part of it is denominated the dorsum of the ilium, 
the lowest part is called the tuberosity of the ischium. 
The projection, on the. right, marked B, is the posteri- 
or, inferior, spinous process of the ilium. The projec- 
tion marked F, is the spinous process of the ischium. 
-D, shows imperfectly the situation of the foramen 
ovale. The line marked a a* is the posterior boundary 

* Lines can give no idea of the form, and an imperfect one only 
of the situation of these ligaments, fox the breadth of the larger lig- 



64 

of the ischiatic notch, and shows the situation of the 
larger sacro-seiatic ligament. The line bb shows the 
situation of the smaller sacro-sciatic .ligament. The 
last divides the ischiatic notch into two parts, an upper 
larger, and a lower smaller, both of which are convert- 
ed into holes, or foramina by the first. 

In order to prevent any misapprehension as to the 
last mentioned point of anatomy, I shall illustrate and 
confirm what has been said in regard to it, by the au- 
thority of the best authors and anatomists. This is 
especially necessary, for the two following reasons ; 1st, 
that the part alluded to is more particularly concerned 
with the subject we are to examine, and 2d, that there 
is evidently some misunderstanding actually existing in 
regard to it, which may be one cause of the apparent 
difference of opinion, between different surgical practi- 
tioners and authors. For the purpose of illustration, I 
shall refer to the most celebrated standard continental 
works on anatomy, since it is well known, by English 
physicians, and regretted, that, there is not an accurate 
and minute s} r stem of anatomy in the English language.* 
Our American anatomists have therefore employed, 
as far as I know, the publications of the continental 
writers of Europe ; and this has been my practice, since 
I had the honour to be a humble teacher of the science. 

Than Soemmering of Goettingen there is no greater 
living authority in anatomy. His elegant monographic 
treatises on the eye, on the ear, on the organs of taste, 

anient varies from half an inch to more than two inches. The lines 
serve, however, to show the manner in which they constitute the two 
foramina. 

* The Edinburgh system of anatomy is a compilation of a hetero- 
geneous kind, very deficient in the descriptive part of the or- 
gans most concerned in surgical practice. This is the most popu- 
lar work in Great Britain. But I cannot help expressing surprise 
that among the numerous translations of French and other conti- 
nental books, a translation of the system of Soemmerring, or of that 
of Sabatier, Boyer, or Bichat, is not to be found. 

In our own country the late Dr. Wistar has published an excellent 
treatise on anatomy, but the descriptions were neither intended nor 
required to be minute, like those of the authors mentioned above. 



65 

and of smell, as well as on other subjects are known to all 
anatomists. His general treatise on anatomy, entitled 
" De Corporis Humani Fabrica," contains the following 
description of the part alluded to, as particularly im- 
plicated in this discussion.* 

" Os ischium, or the ischiadic part of the os innom- 

inatum. 

" It is composed of two branches, an anterior small- 
er, aud a posterior larger. The anterior branch grows 
broader and thicker gradually, from the place where 
the descending branch of the os pubis passes into it, 
and ascending is connected with the posterior branch. 
Its anterior surface is rough, the posterior smooth ; the 
superior edge sharp, the interior broad. 

The external surface of the posterior branch presents 
an obtuse crest, transformed into the prominent margin 
of the acetabulum, and, towards the posterior parts, the 
tuberosity of the ischium, encrusted with cartilage, 
beginning by a contracted part, and, gradually spread 

# " Os ischii, sivepars ischiadica ossis coxa. 

" E duobus ramis, priori minori, posteriori major! componitur. 
Prior ramus, ab eo ind loco, quodescendens ossis pubis ramus in eura 
abitj sensim, latior, crassior evadit, ramoque posteriori adscenden- 
tio adjungitnr. Prior ejus superficies aspera est, posterior laevis ; 
titargo superior acutus, inferior latus. 

Rami posterioris externa superficies cristam obtusam, in promi- 
nentem acetabuli marginem mutatam, et posteriora versus tuber 
ischii cartilagine crustatum, initio contracto ortum, sensimque diduc- 
tum, ovali ambitu terminatum, et ad externa, et posteriora, circum- 
volutum exhibet. \cetabulo et tuberi ossis ischii sulcus, teiidinem 
musculi obturatoris externi excipiens, interponitur. Post ad constitu- 
endam acetabuli posteriorem partem fornicatur, in duas partes abit 
in inferiorem minorem, sive incisuram ischiadicam inferiorem, quae 
musculum obiuratorem internum excipit, et in superiorem majorem, 
^llipticam, sive incisuram ischiadicam superiorem, sive pot'ms iliacam, 
minimam partem ab osse ischii, maximam vero, ab osse ilii consti- 
tutam ; in qua nervus ischiadicus, arteria et vena ischiadica et glutea 
ponuntur. Spina prominens, ischiadica vocata, incisuris interpo- 
nitur. 



66 

out, terminated by an oval circuit, and having the edge 
towards the external and posterior parts turned over. 
Between the acetabulum and the tuberosity of the ischi- 
um, there is a furrow, which receives the tendon of the 
obturator externus muscle. Afterwards, in order to 
form the posterior part of the acetabulum, it is arch- 
ed and passes off into two parts, an inferior smaller, 
or the inferior ischiatic notch, which receives the ob- 
turator internus muscle ; and a superior larger, of an 
elliptical form, or the superior ischiatic notch, or rather 
iliac notch, (for the smaller part of it is constituted by 
the os ischium, but the greater part by the os ilium,) in 
which the sciatic nerve, the ischiatic and gluteal artery 
and vein are placed. The prominent spine of the ischi- 
um, as it is called, is placed between the two notches." 

The anatomical work of Boyer appears to me a 
model of distinct and accurate description, and, in these 
qualities, not to be surpassed. In the account of the 
os innominatum we find the following passage.* 

" Below this eminence" (that is, below the posterior, 
inferior spinous process of the ilium), " we see a consid- 
erable notch which makes a part of the ischiatic notch." 
In the description of the os ilium, he says, " the poste- 
rior edge presents also two notches, one superior, very 
small, (between the spinous processes,) and the other 
inferior, very large, which makes part of the ischfatic 
notch." Again, in speaking of the sacro-sciatic liga- 
ments,t "the two sacro-sciatic ligaments convert the 

* " Plus bas est une autre eminence, formee par la partie poste- 
rieure de la facette qui s'articule avec le sacrum. Cette eminence 
est mediocrement saillante, arrondie, tranchante, et porte le nom de 
Pepine posterieure et inferieure de l'os des iles. Au dessous de 
cette eminence on voit une echancrure considerable, qui fait partie 
de l'echancrure sacro-sciatique." 

f " Les deux ligamens sacro-sciatiques convertissent l'echancrure 
sacro-sciatique en deux trous ; un superieur plus grand et un in- 
ferieur plus petit. Le premier est rempli, dans l'etat frais, par le 
muscle pyramidal, par les vaisseaux et le nerf fessier, par le vais- 
seaux et nerfs sciatiques, et par les vaisseaux et les nerfs honteux. 
Le second est rempli par le muscle obturateur interne, et par les 
vaisseaux et le nerf honteux." 



67 

ischiatic notch into two holes, a superior larger, and 
an inferior smaller. The first is filled, in the recent 
state, by the pyramidalis muscle, by the gluteal vessels 
and nerve, and by the sciatic and pudic vessels and 
nerves. The second is filled by the obturator internus 
muscle, and by the pudic vessels and nerve." 

The " Dictionnaire de Medecine," now publishing in 
Paris, is edited by twenty-six distinguished profession- 
al gentlemen, among whom are Beclard, Chomel, 
Orfila, Pelletier, &c. This work must of course 
speak the language and opinions now received by the 
profession in France. In their description of the os 
innominatum they observe, that " behind the spine of 
the ischium is a deep notch, and another smaller one, 
forming a smooth groove, separates this spine from the 
tuberosity ; these notches are known by the names of 
the gteat and little ischiatic notches."* 

To these authorities I shall add that of Meckel, a 
name long celebrated among the anatomists of Europe. 
In a work lately published by the professor of Halle, 
which has just appeared in Paris, translated into the 
French language, and is considered a valuable acquisi- 
tion to the medical profession,! we find the nomencla- 
ture proposed by Soemmerring, adopted and establish- 
ed ; for, in the description of the ilium he thus speaks 
of the superior notch : 

" The inferior edge [of the ilium] is deeply indent- 
ed : it forms the posterior and superior part of the iliac 
notch.% 



* Une echancrure profonde existe en arriere de l'epine sciatique, 
et une autre plus petite, forraant une coulisse de glissement, separe 
cette epine de la tuberosite : ces echancrures sont appelees la grande 
et la petite echancrures ischiatiques. 

f I am happy to learn that this excellent work is proposed to be 
given to the American public, in an English translation, by Dr. Brad- 
ford of Cambridge. 

| Le bord inferieur est fortement echancre : il forme la partie 
posterieure et superieure de 1 'echancrure iliaque (incisura iliaca, s. 
iliaca superior.) 



68 

In describing the ischium ; " Between its tuberosity 
and the inferior edge of the cotyloid cavity, is found a 
deep depression on the outside. We perceive also be- 
tween it and the spinous process, at the internal face 
and the posterior edge, a notch called inferior iliac, or 
ischiatic"* 

The quotations made above must be sufficient to sat- 
isfy any anatomist that these authors applied the term 
ischiatic notch, not, as some have thought, to the space 
above the letter F in Plate I, exclusively, nor to the 
space below, exclusively, but to both these parts. Boyek 
considers the whole to be one notch, that is, from a to a, 
divided into two parts by the sacro-seiatic ligament ; 
Soemmerring and the editors of the " Dictionnaire" 
make two notches, which he calls superior and inferior, 
and they great and little, ischiatic notches; and Meckel 
gives the name of iliac notch to the whole indentation, that 
of superior iliac, to the upper notch, and of inferior iliac 
or ischiatic, to the lower notch. The nomenclature of 
Meckel is perhaps the most exact, for the reasons as- 
signed by Soemmerring, namely, that the superior notch 
is formed principally by the ilium, and not principally by 
the ischium. If the term ischiatic is retained, it must 
be applied to the notch as a whole, or it cannot apply 
at all to the upper part, this being placed in a different 
bone. The impropriety of confining the term ischiatic 
notch to the upper portion is too obvious to require any 
remark. If its application were restricted beyond what 
has been done by these writers, it should be to the 
lowest part of the notch, which only is really contained 
in the bone ischium. f 

* Entre cette tuberosite et le bord inferieur de la cavite cotyloide, 
se trouve une gouttiere profonde en dehors. On aperc^oit aussi entre 
elle et Tepine, k la face interne et au bord posterieur, une echan- 
crure appelee iliaque inferieure ouischiatique (incisur a iliaca inferior, 
s. ischiatica.) 

f The learned attorney for the defendant alludes, with signs of 
satisfaction, to expressions made use of by me, in which the idea is 
conveyed of a dislocation backwards and downwards in the ischiatic 



69 

Dislocations, or displacements of the thigh bone from 
its socket, may take place in any part of its circumfer- 
ence. When we consider the form of this socket, of 
which some notion may be had from Plate I ; and also 
the form of the head of the thigh bone, as it may be seen 
in Plate II, it will readily be understood, that so far as 
regards the bones, there is no natural obstruction to a 
displacement at any part of the circular rim of the ace- 
tabulum. This opinion is remarkably confirmed by the 
fact, that the point where the greatest anatomical ob- 
struction exists to the escape of the bone, is precisely 
the place where dislocations most frequently occur ; 
that is, at the upper and outer part of the socket. 
Here the ridge of the acetabulum is more elevated than 
at any other part ; yet it is here that the dislocation on 
the dorsum of the ilium happens, the dislocation upwards 
and backwards, a kind of displacement which occurs, 
according to Sir Astley Cooper, in three out of five 
instances of luxation of the hip joint. But although 
the thigh bone may be thrown out in any direction, it 
cannot rest with equal facility on every point of the 
os innominatum. The action of the muscles, or move- 
ments from external causes, would readily carry it back 
to its place, were it not hitched by bony inequalities 
about the circumference of the socket, which serve to 
engage the displaced head of the bone, and to retain it 
in four different situations, according to most authors 
and surgeons. In these places it is confined by the 
inequalities of the bone, aided by the strain put on 
muscles extended beyond their ordinary condition, and 
on the lacerated portion of its ligaments. 

notch, as if this notch did not extend below the level of the socket. 
It is to these expressions I suppose he intended to apply the epithets, 
" absurd, unaccountable, incredible," and it is this idea he would 
call " a perfect fallacy," " a most egregious error," " capable of 
being refuted on the most obvious principles of anatomy." An 
accurate notion of the anatomy of the part must convince him that 
these epithets were misapplied. 



70 

The four situations, taking them in the order of fre- 
quency, are, 

1. On the Dorsum of the ilium, as indicated by the 
circle dd in Plate I. This is called upwards and back- 
wards. 

2. In the foramen ovale, or forwards and downwards, 
indicated by circle D hh. 

3. On the pubes, or upwards and forwards, circle 

E ss- 

4. On the ischiatic notch, downwards and backwards, 
circle F ff. Besides these four cardinal dislocations, 
others have been described. The dislocation directly 
backwards, or backwards and a little upwards, on the 
superior part of the ischiatic notch, or what should be 
called the iliac notch. The last is described in Plate 
I. by that part of the outline included in the circle ee. 
No doubt the head of the thigh bone mav be sometimes 
lodged in places different from any of those just men- 
tioned. Its displacement downward has been described 
by various authors, ancient and modern. I have my- 
self seen it in a situation in which, although I think 
the sort of occurrence has been noticed by some author, 
I could with difficulty have conceived it to remain, had 
I not witnessed it ; that is, upwards and outwards, 
just on the edge of the socket. From such a situation 
it might have been supposed, that the slightest motion 
would have thrown it into its place. Yet there it re- 
mained, and still, I presume, remains, for, when I saw 
it, too long a period had elapsed after the injury, to 
think of an attempt at reduction. 

The four dislocations above mentioned, are represent- 
ed in the annexed Plates. 

Plate II. A lateral view of the os innominatum, 
with the upper extremity of the femur, in the situation 
in which it is, when dislocated backwards, or nearly 
so, the head of the bone being in the upper part of the 
ischiatic notch, or properly speaking, in the iliac notch, 

Plate III. The same view of the os innominatum as in 
Plate II : a, a dotted outline of the upper extremity of the 



71 

femur, showing its position in a dislocation backwards 
and upwards upon the Dorsum ilii ; 6, a representation 
of the upper extremity of the femur, in its position, as 
dislocated backwards and downwards to the lower part 
of the ischiatic notch. 

Plate IV. A front view of the left side of the pelvis ; 
representing also the position of the femur, when the 
head of the bone is dislocated forwards and upwards 
upon the os pubis. 

Plate V. A view of the pelvis, as in Plate IV, and of 
the femur as in a dislocation forwards and downwards, 
with the head of the bone lodged in the foramen ovale. 

While some authors have increased the species of 
this dislocation beyond the number commonly admitted ; 
others, and these of no small note, appear disposed to 
diminish them, or are unwilling to admit the existence 
of all these species. 

Mr. William Hey of Leeds, excelled by few men 
of his time as a practical surgeon and writer, and what 
is more to his credit, by few in his general character, 
seems to admit only two kinds of dislocation : " A 
dislocation of the os femoris at the hip," says he, 
" may happen two ways, forwards and downwards, or 
backwards and upwards." " Seven instances of the 
latter, and three of the former are all that have occurred 
in my practice." " Thirty years had nearly elapsed, 
after the opening of the General Infirmary of Leeds, 
before any patient was brought to it with a dislocation 
forwards and downwards. Nor had I, during a period 
of thirty-eight years, seen that accident in private 
practice." 

Mr. Charles Bell, in his system of operative sur- 
gery, describes two kinds of dislocation only, namely, 
upwards and downwards. 

Mr. Benjamin Bell, author of the System of Surge- 
ry, thus expresses himself on this subject : " It is said 
by authors, that the head of the femur may be luxated in 
various directions, namely, upwards and backwards, up- 
wards and forwards, downwards and backwards, down- 



72 

Wards and forwards, and, I may add, directly down- 
wards ; but I believe few practitioners have met with 
an instance of the first and third." He further says, 
that all practitioners admit the bone to be most frequent- 
ly dislocated into the foramen ovale. " In the disloca- 
tion downwards, the leg will be longer than the other, 
and the trochanter lower, but the knee and toes will re- 
tain nearly their natural situation." It is remarkable 
that of the two species of dislocation, which Mr. Bell 
seems to doubt, one has been proved by the observation 
of other surgeons to be more common than all the rest 
taken together. 

The difference of opinions among surgeons, eminent 
for their knowledge and experience, requires some ex- 
planation. This will be found, I apprehend, in the fact, 
that surgical practitioners of great experience are natu- 
rally inclined to the belief, that they must themselves 
have witnessed every important variety of accident and 
disease, and that what they have not seen does not 
exist. What other explanation can we put on the as- 
sertion of Mr. Bell, that the dislocation on the Dor- 
sum ilii has rarely been witnessed, and that the dislo- 
cation in the foramen ovale is the most common spe- 
cies ? Or how else can we understand that Mr, Sharp, 
the greatest English surgeon of his time, and highly 
esteemed at the present day, should have doubted the 
existence of any hip dislocation ? Mr. Benjamin 
Bell did the same in the earlier part of his practice, 
till experience led him to a different conclusion. Such 
errors will teach us to view, with a reasonable degree 
of caution, the round and positive assertions of practi- 
tioners, who would put down established opinions by 
their own solitary experience ; and they also show us 
the necessity of exercising our own judgments in a fair 
comparison and estimate of opposing facts, as observed 
by different authors. " Desault," says M. Riche- 
rand in his late work, " was too easily persuaded, 
that the surgeon of the greatest hospital in the capital 
must necessarily be the greatest surgeon in the world ; 



73 

supported in this idea by his flatterers, he exaggerated 
to himself the importance of his labours, and renounc- 
ing the attempt to enlighten himself by the knowl- 
edge of his brethren, he founded his reputation on titles, 
of which every day diminished the value." Such 
must be the fate of every surgeon, who, from too great 
confidence in himself, undervalues the opinion of his 
professional brethren, and considers the whole circle of 
surgical knowledge to be comprised within the sphere 
of his own observation. How absurd would it be thought 
for a surgeon in Boston, practising in the midst of a 
population of 80,000 persons, to pretend to have seen 
every variety of accident or disease, which has occurred 
to the practitioners in the state, comprising half a mil- 
lion. He might have seen more than any three sur- 
geons, or any ten, but that he should have observed all 
the variety of cases which has come within the cogni- 
zance of a thousand practitioners, would be thought a 
pretension too comprehensive to be allowed. So it 
would be equally inadmissible for a great surgeon in 
Paris, to pretend to have seen all which could happen 
throughout the world. 

We shall now confine our inquiry more particularly 
to the kind of dislocation supposed to have existed in 
the case under consideration ; — that of Mr. Charles 
Lowell of Lubec. This is already stated to have 
been taken by me to be a dislocation downwards and 
backwards, in the ischiatic notch, such as is indicated 
in Plate III, and the situation of which has been shown 
in Plate I., by the circle ff. The existence of this 
species of dislocation has been doubted, as we have just 
seen, by Mr. Benjamin Bell ; but his opinion cannot 
have much weight in the case, since he equally doubts 
the existence of the dislocation upwards and backwards, 
well known to be the most frequent kind of this accident. 

Besides him, we find three other surgeons of distin- 
guished reputation, who have either questioned or di- 
rectly denied the dislocation backwards and downwards. 
More than a century ago, John Lewis Petit, a dis- 
10 



74 

tinguished surgeon in Paris, declared that he had never 
seen it, and, that he even believed it to be impossible. 
He admits, however, that it may exist when the mus- 
cles are paralyzed, and gives instructions how to effect 
its reduction. This doctrine of Petit does not appear to 
have been generally received ; for the next authority to 
be found in its support, after the lapse of a century, is 
that of Boyer, an excellent surgeon, now living in 
Paris. In his treatise on surgical diseases, originally 
printed in French, translated and published in this 
country by Dr. Stevens of New York, he says: "We 
do not think the femur can ever be luxated downwards 
and backwards, but it may be carried in that direc- 
tion after a luxation upwards and outwards. That, is 
to say, the head of the femur, thrown in the first 
instance on the external iliac fossa, may, if the thigh 
be afterwards adducted by any cause, slip down be- 
fore the upward part of the ischiatic notch, but it can 
never reach the junction of the ilium and ischium. 5 ' 
Whence it appears not only that Boyer denies the pri- 
mary dislocation backwards and downwards, but also 
the primary dislocation backwards ; while the latter 
is admitted by high authorities, who question the for- 
mer. In truth, of the few surgeons who deny the dis- 
location backwards and downwards, there is no other 
that doubts the dislocation backwards. The whole sur- 
gical world seem to be against Boyer on this subject ; 
and his authority in the case is consequently much di- 
minished, especially as he falls into the error we have 
just now had occasion to notice, that of trusting too 
confidently to his own experience ; for Boyer gives us 
no reason why the dislocation backwards, or the dislo- 
cation downwards and backwards, should either of them 
be impossible ; he does not point out any physical ob- 
stacle to such an occurrence ; he does not inform us that 
tne socket is more elevated at the lower part than at 
the upper, or that any other condition of the bones is 
such as to present an insurmountable obstruction in this 
direction. We know, on the contrary, that such ob- 



75 

structions do not exist, and that the resistance to the 
exit of the bone, in an inferior, posterior direction, is less 
than in that which is the most frequent, the superior 
and posterior. 

In the trial of this cause, the opinion advanced by 
me is opposed by the attorney for the defendant and 
his coadjutors ; it is worthy of remark, however, that 
in his support he adduces neither of the authorities 
mentioned above, but only that of Sir Astley Cooper 
in his treatise on dislocations.* 



* An attempt is made to bring forth the opinion of this distin- 
guished surgeon, as uttered in the third edition of his works ; to place 
it in the light of a discovery so recent as not to have found its way 
to the physicians of Boston, though in some wonderful manner re- 
vealed to the attorney and his coadjutors ; and to represent this 
revelation, for so I think he calls it, as a refutation of the " absurd," 
" unaccountable," u incredible," error into which I had so unhappi- 
ly fallen. What are we to think of such a proceeding ? Was the 
gentleman who professes to have so perfect a knowledge of the sub- 
ject, as to persuade himself he could put down and trample on the 
opinion of physicians, was he ignorant of such common works as 
Benjamin Bell, known to every student, and Boyer on the Bones, 
which has passed through two or three American editions ? Or was 
this pretended discovery a manoeuvre, thought to be well calculated 
to dazzle and blind the court and jury ? The most charitable course 
will be to give the learned counsellor full credit for ignorance in this 
case ; for I am not willing to believe an imposition so gross could be 
attempted. 

The discovery imputed by these gentlemen to Sir Astley, is by 
him not claimed nor considered as a discovery ; and the opposition 
in which it is placed to what I had advanced, exists more in the 
glowing language of the attorney than it does in fact. Whether 
there be any difference between the opinion found in Sir Astley 
Cooper, and that which had been given in my deposition, and, if 
any, how great the difference is, will appear on a more exact exam- 
ination of the statement of this author. As the name of Sir Astley 
Cooper has been so often repeated in these remarks, and as these 
gentlemen have attempted to avail themselves of his authority to 
overthrew my opinion, it may be proper in this place to state how 
far we are willing to consider him as a general guide in matters of 
surgical science. 

Sir Astley Cooper was a disciple of Mr. John Hunter, and an 
immediate pupil of Mr. Henry Cline, of St. Thomas's Hospital, the 
latter a gentleman, I believe still living, who was distinguished, as a 
lecturer on anatomy, for his admirable perspicuity, and as a practi- 



76 

If it were necessary for the safety of my reputation 
to oppose doctrines emanating from such high authority, 
my task would be hopeless. Happily this is not the 
case ; the opposition of opinion is more in appearance 
than reality. The attorney and his friends have array- 
ed Sir Astley Cooper in a hostile garb of their own 
contrivance. Strip off this foreign dress, and it will be 
seen there is no material difference between the opin- 
ions expressed in his work, and those which appear in 
my deposition. Sir Astley remarks that he had never 

cal surgeon, for his calmness and steadiness in operation. By his 
own talents and industry Sir Astley elevated himself to the place 
of colleague with Mr. Cltne, as a lecturer on anatomy, and he 
opened a separate course of surgical lectures given by himself only. 
On the resignation of Mr. William Cooper, surgeon of Guy's Hos- 
pital, a gentleman whose name I cannot pass over without express- 
ing my respect for his excellence, Sir Astley was chosen by the 
governors of Guy's Hospital a surgeon of this noble charity ; contin- 
ued to be so more than twenty years, and has but lately relinquished 
this post. When he was elected to Guy's Hospital, I was engaged 
in the service of the institution under Mr. William Cooper, and 
had the honour of being the first to receive the commands of Sir 
Astley. From that time to the present I have been more or less 
in the habit of communicating with him, and have experienced an 
uninterrupted flow of kindness for myself, and of hospitality towards 
my countrymen, whom I have introduced to his notice. Nor have I 
been wanting in the respect due to so distinguished an instructer 
and friend ; for probably I was the first to make his name known, 
and to spread abroad his reputation on this side of the Atlantic. 
And to those who have attended my lectures, I can appeal in sup- 
port of the assertion, that I have quoted no other name more fre- 
quently and none with more respect. In truth, Sir Astley Cooper 
is entitled to all the respect that has been paid to him. He is not a 
mere surgeon,* but a philosopher of the school of Bacon, a careful 
observer of nature, and a reasoner by induction from facts. His 
works are models of practical doctrine, without the least superflu- 
ous theory, or unnecessary discussion, and I have often thought and 
have expressed to him, that surgeons are much indebted to him, for 
giving to the public the fruits of his experience in the more common 
and frequent cases of surgery as well as in those which are rare. 
He is a decided friend to the American nation. If to these points 
of character we add that he is eloquent as a lecturer, and admirable 
as an operator ; that his personal appearance is noble and imposing, 
few men would seem likely to inspire, and to have greater claims to 
general respect than Sir Astley Cooper. 



77 

in his long experience seen the dislocation backwards 
and downwards, and thinks it must be an unfrequent 
accident; but expressly admits its possibility. In this 
I should perfectly agree with him. He asserts that a 
dislocation in the ischiatic notch, or that which, accord- 
ing to the continental anatomists, is the upper part of 
the ischiatic notch, cannot be below the socket of the 
hip. In this, also, I must entirely coincide with him. 
In one place indeed he says, " It is to be remembered 
there is no such accident as a dislocation downwards and 
backwards," but this must be taken not in an insulated 
sense. To get the true meaning of the writer we must 
have in view all he says in relation to the topic. Now 
we find in the first part of his treatise (I speak of the 
third edition, that quoted by the learned attorney in his 
speech) the following passage : " A dislocation back- 
wards and downwards has been described by some sur- 
geons who have had opportunities for observation ; but 
I have to remark that no dislocation of that description 
has occurred in St. Thomas', or Guy's Hospital for the 
last thirty years, or in my private practice ; and I doubt 
its existence, though I would not deny the possibility 
of its occurrence, but am disposed to believe some mis- 
take has arisen on the subject." In a subsequent page 
the same remark is repeated, with the following addi- 
tions and explanations. " If such a case does ever 
occur it must be extremely rare. I cannot help think- 
ing that some anatomical error must have given rise to 
this opinion, as in the dislocation downwards and back- 
wards the head of the bone is described as being receiv- 
ed still into the ischiatic notch ; but this notch is in the 
natural position of the pelvis above the level of the line 
drawn through the middle of the acetabulum ; and 
thence it is that the leg is shorter, not longer, where the 
bone is dislocated into the ischiatic notch." 

From these quotations it appears, that Sir Astley 
Cooper, not having witnessed the dislocation back- 
wards and downwards in his long course of experi- 
ence, was naturally led to doubt its existence ; that 



78 

he expressly disclaims a denial of its possibility, and 
admits that it had been described by persons of ob- 
servation, though he conceives its occurrence to be 
rare ; and that he is disposed to think the supposition of 
such an accident may have arisen from a mistake as to 
the anatomy of the part. 

Now it is obvious that the different representations 
made of this case by authors, have arisen from a differ- 
ent application of terms. Nothing can be more certain, 
than that, in ascribing the error to an anatomical mis- 
take, and in showing this mistake to have consisted in 
the notion that the ischiatic notch was lower than the 
hip socket, Sir Astley Cooper alluded to what we 
call the upper part of the ischiatic notch ; what Boyer 
and the French anatomists generally have described 
to be the upper part, what Soemmerring names the su- 
perior ischiatic notch, or, if rightly denominated, the 
iliac notch. That which Sir Astley calls the ischiatic 
notch, is really above the socket ; but what the conti- 
nental anatomists so name, extends both above and be- 
low. A dislocation in the upper part of it is above the 
socket, and the limb is shortened ; a dislocation in the 
lower part, or on the surrounding bone, is below the 
socket, and in such the limb would be lengthened. 

That such is the true explanation of Sir Astley's 
opinion of the subject, is, I have already said, obvious ; 
for no one will venture to attribute to Sir Astley 
Cooper, or to any other anatomist, the assertion that 
the lower part of this notch, where the obturator inter- 
nus muscle is situated, is above the level of the hip 
socket. It is in fact so much below it, that a disloca- 
tion in which the head of the bone was placed there, or 
thereabouts, would present a limb lengthened from two 
to three inches. 

The explanation of the anatomical error being rightly 
understood, and also the declaration of Sir Astley 
Cooper, that he would not deny the possibility of this 
accident, it must follow, that the weight of his authori- 
ty against its existence is greatly diminished, if not al- 



79 

together removed ; for we have no remaining objection 
on his part, but the fact, that he had not witnessed the 
very case ; but Sir A. Cooper is too much of a philos- 
opher to have made this the principal ground for denying 
its occurrence, as Petit very unceremoniously does. 
The latter tells us roundly, he has never seen such an 
event, and therefore it is impossible. But on what 
ground, let me ask, could Petit, or any one else, assert 
such an occurrence to be impossible ? Where are the 
barriers to it, and what are they ? Do they exist in the 
bones ? I have already shown the reverse. Are they 
formed by ligaments ? these are weaker below than 
above. Or in the muscles ? they are not stronger in 
this than in any other direction. Where then is the in- 
surmountable obstacle that renders this displacement 
downwards and backwards an impossible occurrence?* 

* No doubt it will excite surprise in the minds of some persons, 
that in the vast extent of their practice, neither Sir A. Cooper nor 
Boyer has met with this dislocation, and we may be asked why 
they have not? the reason is plain ; it lies in the rareness of its oc- 
currence. We have no right to demand that one practitioner should 
have seen every accident and disease ; life is too short for an expe- 
rience so extensive ; for while we are in the full career of observa- 
tion, and are gratifying ourselves with the expectation that we are 
soon to see all there is to be seen, and know all there is to be known, 
death comes upon us and cuts all our experience short, and we are 
able to leave but a small part of it behind us. A multitude of instan- 
ces might be adduced in illustration of this statement ; I shall quote 
only one, that of dislocation of the vertebrae of the neck, without de- 
struction of life. Sir Astley Cooper informs us that he has seen no 
such accident ; though he does not wish to deny the 'possibility of its 
occurrence. Yet an instance is recorded by Boyer, who appears to 
have been a witness of it himself, and who speaks of this dislocation as 
an occurrence not unfrequent. " A lawyer writing at his desk, heard 
the door behind him open ; he quickly turned round his head to see 
who was coming in, but could not bring it back to its natural posi- 
tion. Many surgeons of Paris have seen this patient; his head was 
turned to the right, and slightly inclined to the shoulder of the same 
side." Sir Astley's words on the subject are the following: "It 
has been generally said by surgeons, that dislocations of the spinal 
column frequently occur; but if luxation of the spine ever does hap- 
pen, it is an injury which is extremely rare ; as in the numerous in- 
stances which I have seen of violence done to the spine, I have nev- 



80 

We may be asked, why the dislocation spoken of is 
so very rare, as jiot to have been seen even by these 
great practitioners ? In reply to this question I would 
premise, that I do not consider myself bound to answer 
objections to a fact ; it is enough to show its existence. 
However, I am ready to give all the satisfaction I 
am able, and therefore shall assign as the reason for 
the infrequency of this kind of dislocation, the fol- 
lowing considerations and facts. The direction, in 
which the thigh bone is thrown out of its place, must 
depend principally on the direction in which the dis- 
placing power is applied. In order to dislocate the thigh 
upwards and backwards on the ilium, or above and 
without, a force must be applied from below and within. 
Now in injuries accompanied with dislocation of the 
thigh, the force is most frequently applied to the knee 
on its outside and lower part, and the blow is received 
on the outside of the knee in consequence of the 
natural inclination of the thigh bone from without in- 
wards, as it passes from the hip to the knee. If, for 
instance, a man falling from a scaffolding, strike the 
knee, it will usually be on its outer part. If there 
should be a consequent dislocation, the thigh bone will 

er witnessed a separation of one vertebra from another, without 
fracture of the articular processes ; or if those processes remain un- 
broken, without fracture through the bones of the vertebrae ; still I 
would not be understood to deny the possibility of luxation of the 
cervical vertebras." An instance of partial luxation of the cervical 
vertebrae successfully reduced, has, I have been told, recently hap- 
pened in this country, but the circumstances have not been repre- 
sented to me so exactly as to authorize me at this time to cite it. 
The repetition of quotations is not however necessary, I suppose, to 
support the general assertion made above ; since few will deny that 
accidents have occurred, and do frequently occur which the most 
practised surgeons may not have encountered. It is on the subject 
of injuries of the spine, that Sir A. Cooper has been recently attack- 
ed with great violence by a surgeon and author of high standing in 
London. I have alluded to this attack for the purpose of showing 
that the strongest claims on the good will of the profession and the 
public, have not exempted even Sir Astley Cooper from sarcasm 
and reproach. 



81 

be pushed upwards and outwards on the ilium ; and 
this is the reason why this dislocation is more common 
than any of the others, notwithstanding nature has in 
precisely this direction placed the strongest guard of 
bone, ligament, and muscle ; no doubt because it is the 
part most exposed to this accident. While this is the 
most common mode of the application of force to the 
knee, there may be many others which will of conse- 
quence be calculated to give the bone various directions. 
If the force be applied below the knee and on its fore 
part, then, the thigh bone being thrown upwards till it 
tears the ligaments and muscles, its head will issue at 
the lower part of the ligament, and a slight inclination of 
the knee inwards will throw it in a direction to rest on 
or near the outer part of the socket, and in this way 
produce the dislocation backwards and downwards. It 
has also seemed to me probable, in the case of an 
individual falling with his horse, the foot being en- 
gaged under the horse, and the subject coming down 
on the side of the sacrum and ischium, that the weight 
of the animal received on the inside of the thigh, under 
such circumstances, would force the head of the bone 
outwards and downwards. The cause of the infrequen- 
cy of the dislocation downwards and backwards, I 
therefore suppose to be the infrequency of the applica- 
tion of a sufficient power in the direction required to 
produce it. 

Having thus assigned the reasons which might have 
influenced the opinions of Petit, Boyer, and Sir Ast- 
ley Cooper ; having removed in part, if not wholly, 
the objections which might have operated in the minds 
of the two last named surgeons; and having shown 
that there is not any physical obstruction to the occur- 
rence of the accident in question ; I might add that in 
this state of facts, the well authenticated and positive 
evidence of a single instance of its occurrence would be 
sufficient to satisfy an impartial mind. This could in- 
deed be properly said of any such case, described by a 
11 



82 

perfectly disinterested practitioner ; but, as I am now 
situated, such a fact would not, of itself, present suffi- 
cient grounds for confidence. Instead, therefore, of 
bringing forward my own experience in this stage of 
the argument, I shall beg leave to look into respectable 
authors for the purpose of ascertaining, whether the 
opinion formed by me is an insulated one, or whether 
it is supported by good authorities. 

The authorities which I shall prefer in the present, 
as in a former case, are those which are considered most 
popular, and therefore best fitted to represent the gen- 
eral sentiment. The first which presents itself, in this 
light, is the article on the subject of dislocation in the 
Cyclopaedia of Rees.* 

Of dislocations of the hip, this author says, " These 
dislocations may take place upwards and outwards, on 
the external surface of the os ilium ; upwards and for- 
wards on the body of the os pubis ; downwards and 
inwards on the foramen ovale ; and downwards and out- 
wards on the os ischium." 

" Luxation of the femur downwards and backwards, 
may, like that of the humerus inwards and forwards, be 
primary or secondary : it is primary when in conse- 
quence of some effort, the head of the femur is forced 
from the acetabulum, at its inferior and posterior parts, 
and is placed at the junction of the ilium and ischium ,*f 

* The composition or preparation of the surgical articles in this 
work has been attributed to Mr. William Lawrence of St. Bar- 
tholomew's Hospital, a distinguished author, lecturer, and surgi- 
cal practitioner in London. It must be noticed, that the titles of the 
different species of dislocation are a little varied by different authors ; 
though not so much but that a moderate degree of attention will 
show their agreement with each other in meaning. 

f The point of junction of the ilium and ischium might bethought 
too high a situation, when the head of the bone is there, to present 
a luxation downwards. To judge rightly of this,, it is proper to con- 
sider that the upper part of the ischiatic notch is but little above the 
acetabulum, and that, when the head of the thigh bone is there, the 
limb is very little, sometimes not at all, shortened ; that when the 
kead is lodged at the junction of the ilium and ischium, it will be 



83 

it is secondary when it succeeds fo the luxation upwards 
and outwards, the head of the femur, which was placed 
at first in the external iliac fossa, sliding downwards 
and backwards ; its passage in this direction being fa- 
voured by bending the thigh on the pelvis. 

" In these two cases, the head of the femur rests 
against that part of the ossa innominata where the os 
ilium and ischium join ; the muscles which cover the 
posterior parts of the articulation, such as the Pyriformis, 
Gemini, Obturatores, and Quadratus, are raised up and 
stretched ; the Psoas magnus, and Iliacas internus are 
in a state of great tension, and this explains the turning 
of the limb outward. When this luxation is primary, 
the extremity is lengthened ; a hard tumour is felt at 
the posterior and superior part of the thigh ; the gr^at 
trochanter, by descending, is removed further from the 
spine of the os ilium, and the knee and sole of the foot 
are turned outward ; but if it be secondary, the thigh 
is much bent on the pelvis, the knee and sole of the 
foot are turned inwards, because the primary luxation 
has been upwards and outwards. The secondary luxa- 
tion in this direction is much more frequent than the 
primary." 

Omit what relates to the secondary luxation, and 
you have in this description, as nearly as may be, the 
phenomena in the case of Mr. Charles Lowell, 
that is, of a dislocation " backwards and downwards, 
in or about the ischiatic notch ;" for if I had drawn up 
a statement of the symptoms of the case, it could 
scarcely have applied with more accuracy than this ; 
especially the account of the anatomy of the muscles in 
this accident, which, independently of this author, I 
had examined and verified in every particular. Will 
any one believe that imagination could have formed 

considerably lower, and the limb of course decidedly elongated ; and 
when on the lower part of the ischiatic notch and spinous process 
of the ischium, it will be much elongated, that is, to about the same 
degree as in dislocation forwards and downwards, which is well 
known to be frequently equal to nearly three inches. 



84 

these symptoms in my mind, years before I had read 
the description quoted above ? 

In other histories of the case, we find some varieties 
of concomitant symptoms ; but they are not greater 
than might be justly expected, on considering the differ- 
ent degrees of laceration of the capsular ligament of the 
joint, especially when the anatomy of all the parts con- 
cerned in this dislocation is rightly understood. 

The Edinburgh Practice of Surgery contains the fol- 
lowing account of the matter. " From the great strength 
of the hip joint; it was formerly believed, that the head 
of the thigh bone was never luxated by external violence. 
But it is now known that it happens by no means un- 
frequently." 

Having described three other kinds of dislocation, the 
dislocation backwards and downwards is thus spoken of : 
" When the ball slips backwards and downwards, the 
leg is lengthened, the toes turned inwards, and the great 
trochanter is lower than that of the other limb. If the 
ball slips directly downwards, the toes keep nearly their 
natural situation." This last dislocation is apt to be 
converted into that backwards and downwards, for when 
the head of the os femoris slips out of its socket at the 
lowest part, there being no very convenient lodgment for 
it directly under the socket, it glides backwards, and in 
this way the dislocation backwards and downwards may 
sometimes be produced. 

Among the more distinguished French authorities 
on this subject, we find the following. First, the En- 
cyclopedic Methodique, a work produced by the united 
science of the French. " We may," say they, "dis- 
tinguish different luxations, according to the place the 
head of the bone occupies, out of its cavity ; thence the 
different names of luxations ; upwards and outwards, 
upwards and inwards, downwards and outwards, down- 
wards and inwards." 

Richerand, author of the system of surgery called 
Nosographie Chirurgicale, also of the system of Physi- 
ology, and of a surgical work just published, which has 



85 

excited great attention in France and England,* holds 
the language of Rees's Cyclopaedia, or the account given 
by the one is a translation from the other. This, as we 
have seen, agrees more nearly with our case than any 
other history of this accident, and we must view in it 
the united opinions of Richerand, and of the editor of 
the surgical part of the Cyclopaedia. I quote a few lines 
only to show this agreement. " The femur may be lux- 
ated from its articulation with the innominatum, to be 
carried upwards and outwards, on the external face of 
the os ilium ; upwards and inwards, on the body of the 
pubes ; downwards and forwards, in the obturator fora- 
men ; downwards and backwards on the os ischium. "t 
He distinctly states in regard to the latter, that the 
limb is lengthened and turned outwards. 

According to Leveille, author of the systematic 
Work called " New Surgical Doctrine," " the femur may 
be displaced outwards and inwards, forwards and back- 
wards." " The luxation backwards, in posteriorem 
partem, Hippocrates, Celsus ; downwards and outwards, 
impossible, according to Petit ; behind and below, ac- 
cording to Bertrandi ; posteriorem et inferiorem, ac- 
cording to Callisen ; posterior and inferior, Monteggia ; 
is indicated by the flexion on the pelvis of the thigh, 
when in a state of adduction ; by the elongation of the 
limb, the knee, and point of the foot being directed in- 

* This new work of Richerand's is written on the plan of Sharp's 
Critical Inquiry. It contains the most liberal and impartial view of 
French surgery, which has ever appeared. The criticisms on the 
writings and improvements of the French, English, and German sur- 
geons, are some of them excessively severe, especially those on De- 
sault, and Dupuytren, the great surgeon of the Hfttel Dieu ; in some 
of which 1 should venture to disagree with this writer. However, it 
must be allowed that he shows great learning and independence, and 
it is probable his publication will produce considerable improvement 
in French surgery. 

f Le femur peut se luxer dans son articulation avec l ? os innomine, 
pour se porter en haut et en dehors, sur la face interne des os des 
ties, en haut et en dedans sur le corps du pubis, en bas et en avant 
sur le trou obturator, en bas et en arriere sur f$s ischien. 



86 

Wards ; by the great trochanter being lower in front, as 
well as the bend of the hip, flat above, broader below."* 
" The last variety of luxation, is with the capsule lace- 
rated behind, with the head of the bone applied on the 
tuberosity of the ischium, where it is retained by the 
tension of the superior part of the capsule, which is not 
torn, and by the contraction of the muscles attached to 
the trochanter." 

Let it be noticed, that the above passage gives the 
authorities of Hippocrates, among the Greeks ; Cel- 
sus among the Latins ; Bertrandi among the Italians; 
Callisen among the Swedes ; and Monteggia among 
the Italians. AlHn favour of the dislocation backwards, 
and most in support of that backwards and downwards, 
and each of them, at least of the modern authors, at the 
head of the profession in their respective countries ; 
Callisen and Bertrandi are, it is well known, sur- 
geons and authors of the highest rank for learning and 
accuracy ; they are, particularly the former, not to be 
surpassed, for their knowledge and correctness. They 
distinctly maintain the doctrine I have endeavoured to 
illustrate. 

The only additional authority I shall think necessary 
to cite from the French, is that of Delpech, the learn- 
ed Professor of Surgery in the University of Mont- 
pelier. His remarks are very comprehensive, and ex- 
hibit great observation and a profound knowledge of 
the subject : 

* It will be sufficiently obvious that all these authorities are not 
adduced because their description of symptoms accords exactly 
with those of the case in discussion. The principal object of them 
is to establish the disputed fact of a dislocation backwards and down- 
wards. The symptoms are described with some variation by differ- 
ent authors. They all agree that the limb is elongated. The 
direction of the foot is, according to some, outwards, to others, 
inwards, and again, according to others, strait forwards. These 
varieties, as I have explained, are produced by the different degrees 
of laceration of the capsule. When the head of the os femoris is at 
the lower part of the ischiatic notch and spinous process of the is- 
chium, the foot will, I apprehend, rather incline to turn outwards 
than inwards, in most instances. 



87 

" The exact analysis of facts, demonstrates that we 
must refer every luxation of the femur, as to the direc- 
tion of the displacement, to four different species. In 
the first, the head of the bone passes towards the exter- 
nal iliac fossa ; in the second, it is placed on the hori- 
zontal branch of the os pubis ; in the third, it rests on 
the foramen ovale ; in the fourth, the femur is supported 
between the cotyloid cavity and the great ischiatic notch. 
It is probable that the accidental relations established 
by the luxation, do not always take place exactly be- 
tween the same points ; observation demonstrates on 
the contrary, that there are some variations in these 
particulars ; but we may be assured from facts, that the 
articular capsule is always ruptured towards one of the 
points indicated. 

" We have given to each of these species names taken 
from the position of the displaced bone : thus in the or- 
der in which w r e have enumerated them, the first is 
called posterior superior ; the fourth posterior inferior ; 
the second anterior superior ; and the third anterior in- 
ferior. It would be more simple to call them superior, 
inferior, anterior, posterior."* 

He then proceeds to show that the respective frequen- 
cy of these four species depends not so much on the 
anatomical structure, as on the direction of the force ap- 
plied ; for the socket is most elevated at its upper part, 
and yet dislocations are most frequent in this direction. 
The luxation on the ilium upwards, is, he thinks, the 
most frequent ; next, downwards and forwards ; third, 
upwards and forwards ; and in regard to the last species 
he says : " As to the displacement, by means of which 
the femur is carried near to the ischiatic notch ; it has 
been observed so seldom, that respectable physicians 
have even denied its possibility. It is however incon- 
testible that it has occurred ; but it is the most rare of 
all. Some have attributed this last kind of luxation to 
a secondary displacement, which might succeed that, 

The last is the nomenclature adopted by Sir A. Cooper. 



88 

in which the head is lodged in the iliac fossa ; but there 
is nothing to prove the exactness of this assertion. 

" Some writers have thought that certain luxations 
of the thigh might change their direction, by the effect 
of a consecutive displacement ; it has been thought, for 
example, that the luxation backwards and downwards 
never took place immediately, but that it might be the 
remote result of that upwards and outwards, by means 
of a subsequent flexion of the thigh. But in the first 
place, the immediate luxation backwards and down- 
wards can no longer be a subject of dispute in the 
present state of science ; in the second place, observa- 
tion has nowise proved this transformation from one 
luxation to the other ; finally, the slate of the muscles 
in the first species seems to render the secondary dis- 
placement, of which we speak, a thing impossible."* 

These quotations will be closed with two authorities, 
published in our own country ; one contained in the 
surgical system of the late Dr. Dorsey, and adopted 
by him from the French ; the other, from a work re- 
cently translated and published by Dr. Godman. 

" The dislocation of the hip may take place," says 
Dr. Dorsey, " upwards and backwards," (or upwards 
and outwards) " on the dorsum ilii ; secondly, upwards 
and forwards, on the os pubis ; thirdly, downwards and 
inwards, into the foramen thyroideum ; fourthly, down- 
wards and backwards on the os ischium." 

The name of Lisfranc, and his improvements in 
surgery, have lately excited attention in Europe and 
this country. Many of these improvements are indeed 
merely changes, but others exhibit great ingenuity, and 
give him a fair title to the respect of the profession. A 
number of his operations I have practised at the Massa- 
chusetts General Hospital, with much satisfaction to 
myself, and 1 trust with benefit to my patients. An 
account of his practice has been published in Europe 

* Precis Elementaire des Maladies Reputees Chirurgicales ; Par 
J. Delpech. Paris, 1816. pp. 107, 8, 9, and 17- 



89 

by Dr. Costar, which that ingenious naturalist, of 
Philadelphia, Dr. J. R. Godman, has just given to 
this country, with some notes of his own. The work of 
Lisfranc must be considered as the latest statement of 
surgical practice and opinions, having been published 
since Sir Astley Cooper's third edition. It contains 
the following account of the different species of dislo- 
cation of the hip joint. 

" Luxations of the Femur. — This luxation may oc- 
cur in four different directions : 1st, upwards and out- 
wards ; 2d, upwards and forwards ; 3d, downwards 
and inwards ; 4th, downwards and backivards. 

" John Lewis Petit published his opinion on this sub- 
ject in France one hundred years ago, Boyer about fifteen 
or twenty years, and Sir Astley Cooper in England, 
about ten. Yet, notwithstanding these remarkable ex- 
ceptions to the public voice, the general opinion evidently 
remains unchanged, and, as the distinguished professor 
of Montpelier remarks, ' the immediate luxation down- 
icards and backwards can no longer be a subject of 
dispute in the present state of sciences'" 

Such are the authorities in support of the existence 
of the kind of dislocation I had presumed to exist in the 
case of Mr. Lowell. If my presumption in this in- 
stance be charged with the epithets " absurd," " unac- 
countable," or " incredible," it will be seen that I must 
have the honour of participating in these charges with a 
large part of surgical authors.* 

If, however, there be no absurdity in believing the 
possibility of this accident, I may be allowed to state 
the special reasons for adopting such an opinion in this 
instance ; to support this opinion by particular facts, 
which have come within my own cognizance and that 

* I do not wish to be considered, in thus dilating on this topic, 
to be very anxious to convince every one of the species of luxation. 
The difficulty of doing so is, I am sensible, very considerable. What 
seemed principally desirable was to establish the existence of a dis- 
location, and to assign a sufficient number of facts and authorities to 
show there was no " absurdity J ' in my opinion of the species. 

12 



90 

®f other practitioners ; and, further, I may be permitted 
to obviate some difficulties which have been suggested, 
and reply to some remarks which have been made on 
my opinion. 

No one will suppose that I examined all the authori- 
ties introduced, at the time the case of the plaintiff was 
submitted to my investigation. His case appeared to 
me a difficult one indeed, at first view, but I was not 
wholly without knowledge of the opinions of authors 
concerning it, and therefore, after one inspection of the 
patient, thought it sufficient to refer to the treatise of 
Sir Astley Cooper, a copy given me by the distin- 
guished author, and which I had annually referred to, 
quoted, and sometimes exhibited in my surgical lec- 
tures, explaining by its engravings the distinctions be- 
tween these dislocations. The work of Sir Astley did 
not afford support to the opinion of the case, which on 
the whole seemed to me most tenable ; neither did it, to 
my apprehension, declare such a case impossible, and 
I had authorities on the other side ; and, what w r as of 
more weight, the evidence of my own senses. True it 
was, that the phenomena much resembled those of 
another, and more common dislocation ; that, namely, 
which happens downwards and forwards into the fora- 
men ovale. In this state of doubt, I looked for the 
sign, which must in every case be considered patho- 
gnomic, or truly characteristic of the nature of the 
accident ; that is, the situation of the head of the dis- 
placed bone. If I could find this, whatever might be 
the other appearances, the species of the dislocation 
w r ould be satisfactorily made out. Let us suppose, as a 
parallel example, a dislocation of the shoulder, the first 
aspect of which might lead the surgeon to the belief 
of a luxation in the arm-pit ; but that on passing the 
hand over the shoulder, the head of the bone should be 
felt on the scapula. Would his opinion halt after he 
had made this discovery ? The situation of the head of 
the bone is an unfailing indication of the species of dis- 
location. I considered it so, my opinion was formed 



91 

thereon, and subsequent events served to corroborate 
it ; for when I examined the patient, while under the 
action of the pullies, I had the perception of its motion, 
and pointed it out to those who stood around me. The 
authority of books should not, I think, be opposed to 
such evidence.* 

The Hon. Judge informs us, however, that " in this 
dislocation, the head of the thigh bone is described as 
being buried so deep, that it cannot be felt distinctly 
except in very thin persons."! He did not, perhaps, 
recollect, that Sir Astley Cooper was speaking of a 
case entirely different from Mr. Lowell's, when he 
said, that " the head of the bone could be discovered 

* But is it not possible, that I might have been deceived ? Un- 
doubtedly. The evidence of the senses is sometimes fallacious, and 
what seemed to me to be the femur, might have been something dif- 
ferent. The Hon. Judge expresses his conviction that this was the 
case ; and the learned attorney is perfectly certain ; he " knows " it 
was not the head of the os femoris. It might have been a wen, 
an exostosis, a hernia, a piece of the socket, or some non-descript 
tumour. These are possibilities, I admit, and I must admit that my 
senses might have deceived me in the whole of this business. But 
as nature has bestowed no other medium of communication with ex- 
ternal objects, I must continue to trust the evidence of these senses, 
weak and erring as they may be. 

f " Now the plaintiff,' 1 he adds, " has been before you, and you 
will judge, whether he is to be considered a very thin person." I 
must ask, whether it was altogether just and fair to call on the jury 
to take the appearance of the plaintiff nearly three years after his 
accident, as a specimen of what it was, when he had just issued from 
his confinement, and was hobbling with difficulty on crutches. The 
fact is, that his appearance was essentially altered in the interval. 
He had added most materially to his bulk ; and the prominences of 
the bones were, at the time of the trial, well covered with adipose 
substance. He then indeed exhibited the aspect of full health and 
vigor, and bore none of the phenomena, adapted to excite the com- 
passion of the court and jury. When I saw him, the case was differ- 
ent. His appearance was not sickly, neither was he charged with a 
superabundance of fat. He exhibited muscle and bone in such dis- 
tinctness, that all parts, naturally prominent, might be made out by a 
careful observer. I object, therefore, to the presentation of Mr. 
Charles Lowell, in the month of June 1824, as a specimen of what 
'he was in 1821. 



92 

only in very thin persons." Sir Astley was alluding 
to dislocations with a shortened limb ; whereas in this 
the limb was lengthened. Sir Astley alluded to 
those in which the limb is turned in ; in this it was 
not turned in. Sir Astley referred to cases in which 
the head of the bone was above the socket ; in this it 
was below it. In fine, Sir Astley described the lux- 
ation in which the head of the os femoris is imbedded 
in that deep hole at the upper part of the notch, while 
in this, it was from one to two inches lower, on the is- 
chium, or the inferior part of the ischiatic notch. We, 
in fact, spoke of things quite different, and although it 
were true, that in no case could the bone be felt in 
the upper ischiatic or iliac notch, it would not in the 
slightest degree go to prove that it might not be so in 
the lower and superficial part of the notch, or on the 
adjoining os ischium. It is found in the latter case at 
the upper part of the thigh. There it is described as 
being sensible to the touch by Richerand, and there 
it was that I perceived it in the case of Mr. Charles 
Lowell. 

Another exception must be taken to the opinion ex- 
pressed so forcibly by the Hon. Judge.* He appears 
evidently to have examined the book of Sir Astley 
Cooper, from his having made the above mentioned 
reference to it, and moreover states, that, " Page 79" 
in that book (intending page 68,) " gives an example 
of a genuine dislocation into the ischiatic notch, in the 
case of a young man admitted into Guy's Hospital, un- 
der the care of Mr. Lucas." We must suppose, there- 
fore, that he had looked at page 68, and read the account 
of the case. 

* In thus speaking of a judgment emanating from so high an au- 
thority, I wish to be considered as intending to do it with all the re- 
spect consisting with the developement of truth. The person and 
character of the honourable gentleman who sat oh the bench, and who 
has done me the honour of using my name, are as much unknown to 
me as if he were an inhabitant of Great Britain ; but I respect the 
©ffice. 



93 

But it appears that, in this very case, the head of the 
thigh hone was perceivable, and was actually perceived 
by the examining surgeon. Yet this patient is not said 
to have been " a very thin person." At page 79, how- 
ever, we have, in Case 5th of dislocations into the is- 
chiatic notch, a more distinct account of the condition 
of the patient. " James Hodgson, a sailor, a strong, 
muscular man, was admitted into St. Thomas' Hospi- 
tal, &c." After stating the appearances and consequent 
symptoms, he proceeds thus : " Monday evening, the 
14th, the swelling had greatly subsided, and I thought 
I could now feel the head of the bone, on rotation of 
the limb." " Mr. Cooper at my request very kindly 
saw it in the evening, and immediately declared it to 
be a dislocation into the ischiatic notch, and upon his 
rotating the thigh, I could, much more distinctly than 
before, feel the head of the bone in the ischiatic notch J 97 
The reduction was attempted, and in the course of it, 
" we kept the extension up," says he, " about 10 or 12 
minutes before we used the strap to raise the head of 
the bone, and until I thought it had made some progress 
towards the acetabulum. We then continued the ex- 
tension, gradually increasing it, and at the same time 
endeavouring to raise the head of the bone, and turning 
the knee outwards, for about 15 minutes. I had now 
lost the head of the bone" The extension was con- 
tinued some time, and on removing the pullies, the limb 
was found to be reduced. In this case, the head of the 
bone was repeatedly observed, and under circumstances 
resembling those of our case, with this difference, that 
in that here related, the head of the bone lay much 
deeper than in ours ; yet it was perceived, though the 
patient was a ''strong, muscular man." 

Case second of this same dislocation, is the account 
of what befel Wm. Dawson, aged 34, in a quarrel. 
His hip was dislocated, and much swelling followed. 
" On Sunday, 30th of August," says the narrator, " we 
accordingly met, which was fifteen days after the acci- 
dent, and from the complete removal of all swelling, 



94 

the whole femoral bone was satisfactorily traced to its 
rounded head, which was lodged in the ischiatic notch." 
Whether Dawson was thin does not appear. It seems 
probable that he was not " a very thin person," being 
in the prime of life, and having met with the ac- 
cident, whilst rioting and quarrelling with his compan- 
ions at harvest home. 

Thus, in three out of five cases of this accident men- 
tioned by Sir Astley, the head of the os femoris was 
distinctly felt ; in the fourth it. is not noticed whether it 
was felt or not, and in only one of the five is it posi- 
tively stated that it could not be felt ; and it must be 
recollected, that in all these cases the head was more 
deeply imbedded, than in the dislocation downwards. 

I feel myself called on to remark further, that the 
bench on this occasion highly eulogized the skill, suc- 
cess, and wide range of practice of the deponent A., 
evidently for the purpose of quoting with more effect 
the opinion of the deponent, that in this case there did 
not exist any dislocation of the thigh bone. Now I 
would not at any time be understood to call in question 
the justice of that eulogy, and least of all at this part 
of my argument, since it so happens, that this deponent 
has given a distinct and positive opinion, as to the point 
we are considering ; for in his deposition he says, " Both 
when the head of the bone is on the back of the hip 
bone, and when in the ischiatic notch, the head of the 
hone can he distinctly felt by the hand." How is it 
that the bench should have so much regarded the opin- 
ion of this deponent, when opposed to mine, and yet 
passed it altogether without notice, when it happened 
to agree with it ? On the contrary, my testimony, 
even when thus supported, is referred to with obvious 
marks of distrust ; for after having stated that the head 
of the bone can be felt only " in very thin persons," 
and requested the jury to consider whether the plaintiff 
were " a very thin person," and whether his were one of 
those cases, therefore, " in which it would be quite easy 
to discover the head of the bone," he adds, " Dr. War- 



95 

ren, and the other physicians in Boston, however, de- 
clare that the head of the bone was distinctly felt." * 

" The genuine dislocation into the ischiatic notch," 
referred to in the work of Sir A. Cooper by the Hon. 
Judge, is adduced for the purpose of showing that in 
this case the limb is not lengthened, but rather shorten- 
ed, and the knee and foot turned inwards ; " while," 
says he, " Lowell's are represented as turning out- 
wards." Here again I must remark, that the case de- 
scribed by Sir A. Cooper is a different one from that 
of Mr. Lowell. The relations of the head of the os 
femoris, and consequently of the rest of the limb, vary 
in regard to two essential points : 1st, as to the aceta- 
bulum ; 2d, as to the os innominatum. In the disloca- 
tion described in Sir A. Cooper's work, the head of 
the bone is in the superior ischiatic notch, which is 
above and much behind the acetabulum, and the limb 
must in such a case, be shortened, if its length be in 
any way altered. In Mr. Lowell's case, the head of 
the bone was below the socket, and the limb must of 
course have been longer than the other. Next, as to 
the relation between the os femoris and os innominatum. 
In Sir A. Cooper's case, the head of the bone, gliding 

* As the Hon. Judge seems to hold our positive testimony on this 
point at a low rate, I feel myself bound to declare, and I hope it 
will not be imputed to improper motives that I do so, that there are 
few points of the surgical art, to which I have been called to give 
more attention, than those which relate to affections of this part of 
the body. Diseases and injuries of the hip are among the most fre- 
quent subjects of the skill of the surgeon, and during a period o£ 
twenty years, I have had, to use the words of a high authority, " no 
inconsiderable share of experience in these cases $ " having rarely 
been without some instances of them under my hands, and often 
many at the same time, presenting great varieties of appearance, and 
calling for the exercise of the most exact discrimination of the emi- 
nences and depressions, with a view to determine questions of treat- 
ment, in which the health, comfort, and life of the patient were 
involved. Of course, I was not altogether without the practice 
required to discover the condition of parts about the hip joint, and 
to determine, whether there existed changes from the healthy struc- 
ture. 



9G 

backwards to the superior ischiatic foramen, would be 
inevitably turned over, from its inability to draw the 
whole limb so far back. The result of this would be, 
that the trochanter would be rolled forwards, as seen in 
Plate II, and with it the w 7 hole limb, the knee and foot 
being necessarily turned in. But in the dislocation down- 
wards, the state of things is very different. Here the 
head of the bone passes backwards a little space only, 
and the change of place is much greater downwards than 
backwards. The limb does not revolve, or if in any 
degree, but slightly, and that in the direction backwards 
instead of forwards ; for its head is supported against 
the os ischium? as exhibited in Plate III. In this same 
Plate we have an opportunity of comparing the direc- 
tion of the bone in this case, with its direction in that 
of the dislocation upwards and backwards ; we see at 
once the great difference between the relations of the 
head to the acetabulum and os innominatum in the two 
cases ; and may infer the concomitant variation in the 
positions of the limb. 

If we compare the two representations of the os fe- 
moris in Plate III, with the representation in Plate II, 
we may understand its relations with the acetabulum 
and os iunominatum in the three different cases of dis- 
location backwards. At u, Plate III, we see the head 
of the bone, as in the dislocation upwards and back- 
wards on the Dorsum ilii. The limb is much shortened, 
the knee and foot turned much inwards. In Plate II, 
it is seen as in the dislocation backwards into the supe- 
rior ischiatic notch. The limb is but little shortened, 
and the knee and foot turned slightly inwards. In 
Plate III, 6, we see the dislocation backwards and 
downwards. The head of the bone is on the os ischi- 
um, the limb is much lengthened, while the knee and 
foot are turned outwards.* 



* To Dr. Flagg I am indebted for these views of the different dis- 
locations. Having myself examined the phenomena in a number of 
instances, I procured a subject, and requested this gentleman, in 



97 

These are the representations of facts ; they are 
founded on the anatomy of the parts concerned, and 
supported by the surgical observations already detailed. 
I have demonstrated these facts to a class of more than a 
hundred students of medicine and surgery, and exhibited 
to them the manner in which the dislocation would be 
produced, and the position which would be given to the 
limb, in the dislocation downwards, by the prominence 
of the socket bone, the lacerated ligaments, and over- 
stretched muscles. I showed that, in this case, the limb 
would be very considerably lengthened ; that the foot 
and knee might stand forwards, or turn slightly out- 
wards ; and that, above the trochanter, there would be a 
deep depression, corresponding with the region of the 
socket. Moreover it was demonstrated, that the head 
of the bone, when forced from its socket in a direction 
downwards and backwards, lacerating the capsular liga- 
ment, passes below the Pyramidalis muscle, raises the 
Gemelliand Obturator internus, and, to a certain extent, 
takes their places ; that sometimes the muscles may be 
ruptured, but that ordinarily they would remain in a 
state of tension ; that the Obturator externus and Quad- 
ratus would be nearly in the same condition ; that the 
Pectineus and the strong muscles, Psoas magnus, Iliacus 
internus, and short head of the Triceps, would be violent- 
ly extended, and, acting on the bone from without in- 
wards, would press it against the bulge of the socket, 
and thus fix it firmly in its new position ; that the an- 
terior part of the Gluteus medius would be greatly 
strained, and would draw the thigh bone upwards, were 
it not resisted by the prominence of the socket, together 
with the action of other muscles. 



whose anatomical and mechanical skill T had great confidence, to 
examine and represent the parts in the dislocation in question, and 
to ascertain how far they agreed with my views. Dr. Flagg made the 
examination by himself; and I had the satisfaction to find that the 
result confirmed me in the impressions received, and the opinions 
formed thereon. 

13 



98 

Such a view of the anatomy of the parts concerned 
must, I think, satisfactorily show the possibility of the 
existence of a dislocation backwards and downwards, 
and the accordance of the phenomena indicated with 
those of our patient in points essential. The state of 
rotation may seem to present an exception to this re- 
mark ; but it has been shown already, that this condi- 
tion may be varied by circumstances, in the same 
manner as happens in regard to fracture of the neck of 
this bone, in which case, though the limb is usually 
turned out, it sometimes turns in. This opinion will 
be confirmed, on considering that the round head of the 
os femoris is sometimes resting on the plain surface of 
the ischium ; and that the position assumed by it will 
be influenced by the degree and direction of the dis- 
locating force, as well as the subsequent condition of 
the capsular ligament. The action of the muscles, too, 
while it is always to be kept in view, is not to be con- 
sidered in an insulated way, but in connexion with the 
situation of the bones and ligaments. For the muscles 
that tend to draw a bone in any given direction, may 
actually prevent it from proceeding in that direction, by 
pressing it against a ligament, or another bone. 

To say that the head of the bone in the case in ques- 
tion was situated on the os ischium, may, on a super- 
ficial view, be considered as a contradiction of my 
former opinion. It is not so, however ; this opinion 
was, that the head of the bone was lodged in or about 
the ischiatic notch, and this was as near the fact, as I 
could properly speak. From a survey of the anatomy 
of the parts since, I should be disposed to believe that 
the situation of the head of the bone was probably at 
the lower part of the ischiatic notch, on the plain sur- 
face in front of the spinous process of the ischium. It 
is easy to quibble about the term " ischiatic notch," but 
I dispute not for words, but facts. I said that the dislo- 
cation was of a particular species, and distinguished that 
from what may be called a sub-species, by the term 
dowmvards. If this last expression had not been used, I 



99 

might have appeared to confound it with the dislocation 
backwards. Whether it was in, or near, the ischiatic 
notch, however, it was equally a dislocation belonging 
to this one of the four species commonly admitted, and 
generally designated by the terms I used. 

The manner in which the injury is said to have been 
received, seems to confirm this opinion of the nature of 
the case. It appears that Mr. Lowell fell on his back, 
inclining a little to the left side. Probably he struck 
the ground with the os sacrum and left ischium, receiv- 
ing at the same instant the weight of the horse on the 
inside of the thigh. The knee, and perhaps the foot, 
were in consequence fixed to the ground by the same 
weight. In this situation, if the bone were driven 
backwards out of its place, by the pressure on the in- 
side of the thigh, the head of it would be carried 
downwards and outwards, in consequence of the con- 
finement of the foot or knee. Such at least was the 
impression conveyed to me by the description of the 
patient, at a time when he could have no possible in- 
ducement to misrepresent the circumstances. Such, 
or nearly such, also, is that conveyed by Reynolds' 
deposition, for there is a slight degree of obscurity 
about this testimony, arising probably from the con- 
fusion incident to the circumstances of such accidents. 

The deponent A. intimates that a different impression 
was given to him, by the plaintiff's description, the im- 
pression, namely, that he fell on his hip, from which he 
concludes that the bones were broken and not dislocat- 
ed. He reasoned, therefore, as before observed, from 
erroneous data. 

That a dislocation, and what is more to the purpose, 
an ischiatic dislocation, might occur in circumstances 
similar to those of Lowell's accident, is proved by a 
case related by Sir Astley Cooper. It is that of 
" John Norgott, aged 40, who was carried into Win- 
chester hospital twelve days after his accident. He 
reported that his horse had fallen with him, and on 
him, so that one leg was under the horse, while his 



100 

body was in a half bent position, leaning against a 
bank." The injury proved to be a dislocation into the 
superior ischiatic notch, which was reduced and the 
patient cured. It may be said that a dislocation back- 
wards, in this way, gives no support to the probability 
of a dislocation backwards and downwards, from a 
force applied in a similar way. I am of opinion how- 
ever, that it does afford support to it. It is obvious 
that, if it should happen that the knee or foot were 
caught under the horse, and the limb were in these cir- 
cumstances dislocated backwards, as in Norgott's case, 
it would be more likely to be driven downwards and 
backwards, than directly backwards ; because the head 
of the bone in such a case would be compelled to de- 
scribe the arc of a circle, instead of moving in a direct 
line backward from the socket, and this I suppose to 
have happened in Lowell's case. 

This opinion is confirmed by the following account 
of a dislocation downwards, produced by an application 
of force in the same direction as in the case of Mr. 
Lowell. " M. Ollivier of Angers, in the third volume 
of the General Archives of Medicine, has described a 
luxation of the femur directly downwards, observed by 
himself." This " was produced by the stroke of a 
large branch of a tree, which in falling struck the in- 
ternal and inferior part of the thigh of a man who had 
fallen to the ground, and pushed it violently in abduc- 
tion," that is, outwards. 

This accident demonstrates that a force applied on 
the inside of the thigh is adequate to producing a dis- 
location downwards ; while Norgott's case shows, that 
a force in a similar direction may produce a dislocation 
backwards ; certainly therefore a force so applied may 
be supposed adequate to produce it in an intermediate 
direction, or downwards and backwards, as happened 
in the case of Mr. Lowell. 

" The signs observed," in M. Ollivier's case, " were 
these ; a slight flexion of the thigh on the pelvis with 
abduction, and a feeble rotation of the limb inwards. 



101 

The thigh was a little flexed. There was no sensible 
elongation of the thigh, on account of the oblique direc- 
tion of the luxated bone. The bend of the groin was 
deeper than that of the opposite side, without however 
a great depression ; the great trochanter was situated 
lower than in the natural state, and the hip rounded, and 
more prominent than that of the opposite side, especial- 
ly when the patient was examined by placing him at 
the foot of a bed, after having made him bend both 
thighs ; it did not form folds inferiorly with the thigh. 
The head of the bone was not distinctly felt ; extension 
of the thigh on the pelvis was impossible ; motions of 
adduction could be slightly executed, though with pain ; 
abduction was possible to a greater extent ; the patient 
when lying on the back, kept the limb slightly flexed." 

In this case the limb is said not to have been elong- 
ated, on account of its obliquity. By this is meant, 
probably, that the limb did not appear elongated, be- 
cause it could not be straitened ; for as the head of the 
thigh bone was directly below the socket, the thigh 
must have extended lower than the other, had the two 
been placed side by side. 

Further it appeared from this case, that, when the 
head of the os femoris rested below the socket, there 
was a feeble rotation inwards. From this fact we have 
a right to infer that, if the head of the bone had glided 
backwards to the ischiatic notch and its spinous pro- 
cess, the rotation would have been outwards, necessa- 
rily, in consequence of the inclination of that part of 
the ischium. 

In another part of the description quoted above, we 
find the following passage. " We must, however, 
make the remark, that, in the different luxations of the 
thigh, we observe, in different subjects, slight differences 
in the relations of the head of the thigh bone, and 
in the lesions of the neighbouring parts ; differences 
which probably depend on the greater or less degree 
of violence with which the displacement has been ef- 



102 

fected, arid on the greater or less time since it had 
taken place."* 

There remains only one species of proof applica- 
ble to such a case, which has not been exhibited. Sir 
Astley Cooper has elucidated and confirmed many of 
his accounts of dislocations, by descriptions of the 
actual appearances of the injured parts, as seen in the 
dead body. Evidence of this kind indeed must afford 
incontrovertible proof of the existence of particular spe- 
cies of dislocation, and if we could discover a morbid 
specimen, or the description of one, exhibiting the head 
of the bone displaced in a direction backwards and 
downwards, it would be a complete demonstration of 
the point in question. But the concurrence of circum- 
stances necessary to the existence of such a prepara- 
tion, would be more than could reasonably be expected 
an so rare a case. To produce this, we must have, 
1st, a case, such as was never seen by Petit, Boyer, 
or Sir Astley Cooper ; 2dly, the bone must have 
remained unreduced ; 3dly, the patient must have died ; 
4thly, his body must have been examined ; 5thly, the 
surgeon must have known and distinguished the case ; 
and, 6thly, he must have described it for the benefit of 
the world. 

Such a concurrence of circumstances, I repeat, is 
hardly to be expected; and yet it has actually existed, 
and affords me the means of supplying the remaining 
link in this long chain of facts. There is a case in 
which the head of the os femoris is so situated as to 
demonstrate the dislocation downwards and backwards 
to the senses, a case in which the bones are no longer 
covered with flesh, nor their relations in any respect ob- 
scure. This preparation exists in the collection of Pro- 
fessor Du Pui, of the University of Leyden, one of the 
most scientific surgeons of the present day. It was ob- 
served and prepared by himself. Dr. Dylius, in his 

* These quotations are from the " Dictionnaire de Mededne/' 
T. XIII. Article « Luxation." 



103 

treatise " de Claudicatione," speaks of it in the following 
terms : " As to the fourth species of dislocation, on 
the os ischium, no specimen is given on either side of 
the body in a well-formed acetabulum, so far as I know, 
but if any one regard the remarkable inclination of the 
pelvis, certainly he cannot doubt the possibility of the 
existence of this species. Assuredly the head of the 
bone may slip to this part, as there is certainly a recent 
and excellent specimen in the collection of the celebrat- 
ed Du Pui, where the capsule of the joint being relax- 
ed, the head of the femur is placed, not indeed on the 
os ischium ; but in its vicinity, on the sacro-sciatic liga- 
ment." * Thus it seems that the bone is, in this mor- 
bid specimen, placed on the sacro-sciatic ligament. 
But the place where I supposed the head of the os fe- 
moris to be lodged in the case which we have been con- 
sidering, is the plain surface of the os ischium, in front 
of the spinous process of this bone, marked F in Plate I. 
Now the ligament, referred to by Dylius, is fixed to 
this process, and extends backwards and rather down- 
wards, as will appear from considering the inclination of 
the process. The head of the os femoris, placed on the 
sacro-sciatic ligament, would therefore be situated lower 
than the point indicated by me as the situation of it m 
this accident, and would produce an appearance more 
strongly marked than in the case of Mr. Lowell. 
This morbid specimen therefore must be considered as 
conclusive and incontrovertible evidence of the actual 
existence of such a dislocation, as I pronounced to exist 
in this case. 



* " Quartae tandem speciei, in Ischii osse, quantum scio, ad utram- 
que latus, acetabulo saltern perfecte formate-, nulla datur species, sed 
si quis pelvis modo memoratam inclinationem animadvertit, dubitare 
certe de hujus speciei possibilitate omnino nequit. Potest certe 
hue versum elabi femoris os, quale recens egregiumque certe exem- 
plum servat in sua collectione celeberrimus Du Pui, ubi laxata ar- 
ticuli capsula, non quidem ad os ischium, sed in ejus vicinia, ad liga- 
mentum sacro-sciaticum locatur femoris caput." 



104 

Since the preceding remarks Were written, another 
observation has fallen under my notice, which presents 
a case of the dislocation backwards and downwards 
with a more full and precise view of the condition of 
the parts concerned. 

" The luxation on the ischium, or the ischiatic fossa," 
says the writer, " is often more difficult to recognise 
than the former." After assigning, as the reason of this 
difficulty, the want of shortening of the limb, he pro- 
ceeds to quote, from Sir Astley Cooper, the symp- 
toms of dislocation in the ischiatic notch, and then re- 
lates the following case with the subsequent examination 
and dissection, as an instance of this dislocation. 

" In a man affected with this luxation and observed 
at Angers by M. Billard, the great trochanter formed a 
pretty strong projection on the outside, and a little for- 
wards of the bend of the groin ; the hip, slightly de- 
pressed above and within, was prominent without and 
below. This wounded man having died two hours 
after the accident ; on dissection we found the head of 
the femur situated in front of the ischiatic notch, applied 
on the external part of the spinous process of the ischi- 
um ; it had passed below the united tendons of the 
Pyramidalis and Obturator internus muscles, which 
obliquely crossed the neck of the bone, by passing 
above it ; the two muscles Gemelli were torn, and the 
Quadratus raised and strongly extended. The cotyloid 
cavity vjas partly covered by the Iliacus and Psoas 
muscles, the contorted fibres of which were strongly 
extended, as well as those of the muscles Pectineus, 
Obturator externus and short head of the Triceps."* 

The agreement of this statement of the anatomy of 
the accident is so accordant in every respect with what 
I have already represented to be the actual situation of 

* This observation is found in a volume of the Dictionary of 
Medicine already quoted. The authors of the surgical part of the 
volume are Cloquet, Marjolin, Roux, and Murat ; all of them 
anatomists -and surgeons of the first rank in France. 






105 

the parts, that I should scarcely have ventured to print 
this, after my own account, had not the sheets, contain- 
ing my views of the matter, been already out of my 
possession, and in the hands of the publisher. This 
observation of Bii.lard is sufficient, of itself, to over- 
throw all the reasoning set up on the presumption of 
the impossibility of such an accident. 

It is only necessary to notice, in conclusion, that this 
case is found in a studied article on luxations, contained 
in a scientific work, intended for general circulation, 
and resting its claims to public attention upon the ful- 
filment of the pledge, given in its Prospectus, that it 
shall be " as complete as possible," and that " it shall 
present a faithful representation of the present state of 
the science on every subject, which it discusses, without 
neglecting any fact, or even any opinion concerning it." 
In such a work we find a case of dislocation recorded, 
in which the head of the femur is found, on dissection, 
to be as nearly as possible in the situation, in which I 
supposed it to be in Mr. Lowell's case ; and the 
writer, moreover, agrees as exactly with me in the 
name, as in the place, of the dislocation. He calls it 
" a dislocation in the ischiatic notch " (luxation dans 
la fosse ischiatique) ; and, what is more, he does this 
with Sir Astley Cooper^s book before him. 



14 



REMARKS 

ON SOME PARTS OF THE CHARGE FROM THE BENCH, AND THE PLEA 
OF THE ATTORNEY FOR THE DEFENDANT. 

Not without great reluctance do I feel myself called 
on to advert, in this place, to some statements contained 
in the speeches mentioned above, which from their de- 
scription, could not be noticed before, without interrupt- 
ing the train of facts. We must first advert to the 
peculiar manner in which the Honourable Bench seems 
to have employed a certain review of Sir Astley 
Cooper's book, in the New England Medical Journal. 
It appears that this review contains sentiments favour- 
able to Sir Astley Cooper ; " and that the publish- 
ers particularly extract the results of Sir Astley Coop- 
er's observations in regard to dislocations of the hip ;" 
and these observations are quoted to refute the doctrine 
advanced by me. Thus far it is well. But the Judge 
would also make me responsible for the opinions of this 
review, or, in other words, he would employ it to make 
me contradict my own opinion and confute myself. 
On what grounds is this severe judgment rendered to 
me ? 1st, because the " Massachusetts Medical Jour- 
nal" is " issued, if not avowedly under the sanction 
yet supported by the physicians attached to the Mas- 
sachusetts General Hospital." 2dly, because the 
number in which the review appeared, contains an ar- 
ticle " furnished by Dr. John C. Warren." 3dly, 
" that it is followed by an account of an operation, prob- 
ably that to which the patient submitted, for a disloca- 
tion into the ischiatic notch." Can any of these reasons 
prove me to be the author of the review in question ? 
As to the first, it should have been known that, of eight 
consulting physicians, and two attending the Massachu- 
setts General Hospital, only the two last, Dr. Jackson 
and myself, ever had any connexion with the New 
England Journal. Of course this publication cannot 



107 

be considered as sanctioned by the physicians of the 
Massachusetts General Hospital. 2dly, the fact of my 
name being attached to one article does not prove that 
I was an editor of the publication, since every body 
knows that such articles are furnished by the profession 
generally, and that the addition of the name to an 
article is considered evidence of its not being editorial. 
3dly, it would puzzle a superficial inquirer to ascertain 
what is meant by the " account of the operation, prob- 
ably that to which the patient submitted, for a disloca- 
tion into the ischiatic notch." On a little research, 
however, it will appear, that this account of an opera- 
tion is an item in a list of operations, printed at the 
latter part of the said number, in the form of an ad- 
vertisement, from the Medical School in Boston, to 
medical students. Such are the grounds on which I 
am made to adopt opinions thought to contradict those 
I had before given. The Honourable Judge perhaps 
confounded three bodies of men, which are perfectly 
distinct from each other, namely, the physicians and 
surgeons of the Massachusetts General Hospital, the 
profeNSors of the Medical School of Harvard University, 
and the editors of the New England Journal of Medi- 
cine and Surgery. The truth is, that though I was 
one of those, who proposed the establishment of the New 
England Journal of Medicine, and was for many years 
an active editor ; yet at the time of the said publication, 
I was not so, and never saw one article of that number 
of the Journal, as editor. But even, if we were to allow 
the full force of his argument, and admit that I had 
been an editor of the New England Journal at that 
time, was there a propriety in making me responsible 
for the opinions of an article, standing with this title 
glaring at his head, — " From the London Medical 
Review," a book printed on the other side of the 
Atlantic ? 

The Honourable Judge throws out an intimation, that 
the case of Mr. Lowell has the signs of a dislocation 
in the foramen ovale. Can this be made to accord 



108 

with the very decisive opinion of deponent A, whose 
character and skill the Judge has so greatly praised ? 
This deponent denies the existence of any dislocation, 
and he is supported by all the depositions from physi- 
cians on that side. The Judge does not appear to have 
examined the patient, but founds this suspicion of his, 
on the general resemblance of the symptoms to those 
of the supposed species of dislocation. The Honourable 
Judge may be in the right ; yet it must be remembered 
that his notion, not only is not supported by any direct 
examination of his own, or that of any medical person, 
but that it is in opposition to all the direct testimony in 
the case, from every quarter. Some of the deponents 
on the negative side have shown disposition enough to 
counteract the evidence given by those who first exam- 
ined the case. If they could have discovered sufficient 
foundation for maintaining the doctrine of the disloca- 
tion forwards, is it not to be presumed they would have 
done it? or with the dispositions manifested, would not 
some of them have done so, with a view to increase the 
confusion and uncertainty of this case ? and, if any of 
them who saw the patient had this opinion, could they 
be justified in concealing it, or rather were they not 
very criminal in doing so ? The Judge appears to have 
been much influenced in forming his judgment, by a 
consideration of the manner in which the patient came 
by his misfortune. I have already remarked that 
reasoning on such sort of evidence is apt to be falla- 
cious, on account of the great uncertainty as to the 
precise way in which accidents of this kind take place. 
I apprehend he may have been led to this opinion by 
misapprehending the fact on which he builds. " The 
thighs," he says, " were widely separated w 7 hen the 
original injury was received, and it is from this cause, 
as Sir Astley Cooper states, that this species of 
dislocation arises." I cannot find it recorded, in the 
deposition of the only man who saw and gave testimony 
of the events of the case, that the thighs were widely 






109 

separated,* nor was it so represented by the plaintiff. 
Has not the Judge mistaken an expression, found in Sir 
Astley Cooper'' s book on dislocations, for one supposed 
to be contained in the deposition ? 

In order, apparently, to convey to the jury more 
forcibly the impression of the errors into which we 
had fallen, the Judge, while he professes that " this 
is a point to which he would be understood to speak 
with less confidence, as the supposition is without the 
direct support of professional testimony," adds at the 
same moment, " If it was a dislocation of this kind, the 
mode of reduction is very different from thai which is 
required in cases of dislocation into the ischiatic notch," 
True, it is so. In a desperate case like this, however, 
it is presumable to those, who are willing to look on 
both sides, that the surgeon would vary the application 
of his powers in every possible manner, before he 
abandoned his patient. We have already intimated 
that, in this unscientific way of operating, as is well 
known to all practitioners, many bad dislocations have 
been reduced, as well by systematic, as by irregular 
surgeons. 

Finally, we must notice these expressions. " Not- 
withstanding," says the Honourable Judge, " the fail- 
ure of this experiment, however, these gentlemen persist 
in their original opinion, and depose to that, effect in 
this case." . Astonishing ! that we should persist in 
our original opinion, because we had failed in re- 
ducing a dislocation which we did not expect to re- 
duce ! But I forbear any further remarks. I would 
not hazard the imputation of a wish to diminish the 
respect due to a Judge of the Supreme Court ; espe- 
cially as I have not the least suspicion of the existence 
of any improper intention. It is obvious from his own 
acknowledgement, " that he had expressed himself 
somewhat strongly ;" that the feelings of this gentleman 
had, from some cause or other, been drawn too much 

* See Reynolds's Deposition, Appendix No. II. 



110 

to one side of the case, so that it was not easy for him 
to see all the facts through the clear medium of a perfect- 
ly impartial and dispassionate judgment. I should not 
have ventured to say so much, had I not been com- 
pelled to do so by the respect I owe to public opinion, 
as well as by a sense of duty to my colleagues, the 
consulting physicians of the hospital, which, under actual 
circumstances, appears to me paramount to the other 
considerations alluded to. 

In the course of the remarks made by the attorney 
for the defendant, we find a frequent recurrence of the 
terms, " Boston Faculty," u Boston Doctors," 
" Boston School;" and a "Boston Jury" is in- 
troduced in order to impugn their impartiality. Even 
the public institutions of this place and its vicinity are 
alluded to in terms of derision. " Is Harvard," says 
the attorney, " a faculty of infallibles, or the Massa- 
chusetts, a hospital of incurables ; " and again, " bring 
down upon him the whole weight of the Harvard Med- 
ical Faculty, piled upon the Massachusetts General 
Hospital." Such attempts to effect an object of indi- 
vidual interest, by exciting prejudices against valuable 
public institutions, and the population of a whole town, 
are indications of a bad cause. Harvard, I must tell 
the learned attorney, is a name, that no American 
should ever couple with expressions of ridicule. From 
Harvard emanated that spirit, which, after nourishing 
the principles of freedom for more than a hundred years, 
burst into a stream that spread over the whole commu- 
nity. To Harvard it is we owe our Hancocks and 
Quincys, and Otises, and Adamses, and Cushings, 
and Dexters, and Lowells, and others, the first mov- 
ers, and daring leaders of the revolution. 

Nor is the Harvard of the present day so degenerate 
from its former literary and political reputation, as to 
merit the obloquy of the attorney. The spirit of im- 
provement is awake there ;* advances in the system of 

* The introduction of gymnastic exercises, which I have long de- 
sired and promoted, is among the improvements now happily made : 



Ill 

education are making, as rapidly, as established habits 
and prejudices permit, and that the result will be highly 
important to this country cannot be doubted, when 
we see engaged in the plans of melioration, the talents 
and earnest efforts of such men as President Kirkland, 
Judges Prescott, Jackson, and Story, Mr. John 
Lowell, Mr. Webster, Mr. Pickering, Mr. Sulli- 
van, Mr. Everett, and Professor Ticknor, and 
others, whose names might be added to the noble list. 

That the Massachusetts General Hospital should 
have attracted the sarcasms of the attorney is not in 
the least surprising. Some persons might have felt 
disposed to exempt a public charity from such remarks ; 
but the general tenor of the argument in this trial 
would entirely preclude all such expectations. We 
notice, therefore, without wonder, various satirical 
expressions besides those already quoted ; as for exam- 
ple, " The works of surgery are full of the most tragic- 
al catastrophes, though few, perhaps so melancholy as 
that which seems to have attended the outset of the 
Massachusetts General Hospital." And again, " The 
result will stand recorded as a most inauspicious augury 
for the Massachusetts General Hospital." 

Whatever evil omens the counsellor and those with 
whom he sympathizes may have seen, and whatever 
inauspicious auguries they may have drawn, have proved 
as fallacious as they were uncharitable. 

This institution has, since the year 1821, been grad- 
ually rising in public estimation, overpowering the prej- 
udices of the weak, and acquiring the confidence of the 
intelligent, till it has now obtained a footing too firm 
to be shaken. Its popularity is very justly founded on 
the many peculiar advantages it possesses. The apart- 
ments are neat and well ventilated in summer, and 
comfortably warmed* in winter ; the food and med- 

and will, in due time, give a different aspect to the sons of our Alma 
Mater, and to the educated youth of the whole country, spreading, 
as it will, by the force of so distinguished an example. 



112 

icine are of the best quality ; all the accommodations the 
sick can require, are in a state of perfection not attain- 
able in most private houses. These circumstances, to- 
gether with the permitted visits of friends, the regular 
superintendance and interest of the trustees, and a con- 
fidence in the good intentions of the medical attendants, 
make this a desirable place of resort.* We find there- 
fore, not only a general disposition in the sick poor to 
enter its doors, but many in easy circumstances prefer 
the hospital to a private house. The most distant 
places and States send patients to the Massachusetts 
General Hospital, the rich and respectable, as well as 
the poor and friendless ; and none, besides that in which 
it stands, contributes a greater proportion of inmates 
than the State of Maine. Nor in truth has any other 
a stronger title to its use, for it is well known that the 
members of the legislature, from Maine, while that 
State and Massachusetts- were connected, afforded an 
important aid towards the foundation of this hospital. 
The inhabitants of the seacoast of that State have 
learnt, that, after transporting themselves in a vessel, 
at a small expense, they can, if their cases are proper, 
enter at a very low rate, or if they are poor, even with- 
out any fee or reward ; that they can remain till they 
recover, if they are curable, and should they be desti- 
tute of means to return to their homes, that there are 
never wanting charitable individuals to afford them the 
necessary aid even for this purpose. They know that 
there is no distinction between citizen and stranger ; 
tiiat this hospital opens its doors to every human being ; 
and that, whether he be an inhabitant of Boston, East- 



* When General Lafayette was in Boston, he visited this hos- 
pital, and was so forcibly impressed with the excellence of its ar- 
rangement, that his secretary afterwards applied to me for the details 
of the economy of the house, with the intention of carrying them 
with him to France. This hospital is also the medium through which 
meliorations, made in other places, in the comfort and economy of 
the sick, as well as mechanical improvements for their benefit, are 
introduced in this part of the world, and soon made generally 
known. 



113 

port, or the Sandwich Islands, he gets admission on the 
same terms, and receives the same attentions.* 

The Massachusetts General Hospital is the most 
noble monument of the triumph of benevolence, which 
Boston has to exhibit. In a community, not extensive, 
a subscription of more than one hundred and fifty thou- 
sand dollars, for one charitable purpose, is not an ordi- 
nary occurrence ; an annual subscription of one hundred 
dollars each, from a considerable number of individuals, 
is not an event to be recorded of many towns of the size 
of Boston. t The benefits of this hospital have been 
experienced by more than twelve hundred sick persons, 
many of whom, no doubt, but for the assistance pro- 
vided there, would have been mouldering in their 
graves ; and it is to be considered, that this aid is not 
extended for a day, or a week, but that it is continued 
till its object is effected. The proportion of successful 
cases will bear a comparison with that of any known 
public institution. In the year in which the list of sur- 
gical cases and operations, alluded to by the Honourable 
Judge, was published, out of about one hundred cases 
of diseases and operations, only two patients died, and 
those from violent injuries, in consequence of which 
they came to the house. A success so remarkable 
cannot be expected to occur again, perhaps in the long 
annals of the institution which posterity may see. 
But I would not have it thought for a moment that I 
attribute it to any peculiar skill or attention, on the 
part of the attending surgeon of the institution. No, 

* The public opinion of this institution is evinced by the progress- 
ive increase in the number of patients. 

Remaining and received during the year 1822 - - 122 

" " " 1823 - - 207 

From April 1, 1824, to April 1, 1825 - - 409 

" " 1825 " 1826 525 

t The president of the hospital corporation, who may be consid- 
ered the father of the establishment, since by his liberality it received 
a donation, the magnitude of which gave an impulse to all the 
others, contributes two hundred dollars annually, towards its support, 
and to his other liberalities there is neither sum nor end. 

15 



114 

so far as obvious causes are concerned, it is to be im- 
puted to the excellent situation and internal arrangement 
of the establishment ; but I should think it as short- 
sighted, as it would be arrogant, to look anywhere for 
the source of this extraordinary success, but to HIM, 
who is the great Fountain of life and health.* 

* See Appendix Z. 



APPENDIX. 



No. I. 



The following statement of the testimony of J. A. Lowell, one of the witnesses 
for the plaintiff, and Joseph Coffin, a witness for the defendants, is extracted 
from the " Report." It will show the nature and grounds of the charges 
against the latter. The names of the defendants are omitted, their places 
being supplied by letters. 



Joshua A. Lowell testified, that he was clerk to the plaintiff in 
1821, when he had his hip dislocated. He was called by Mr. 
Stearns into the room, where they were trying to set it. There 
were several persons present. The witness proceeded to give an 
account of the operation performed by Dr. I. with Dr. K. Mr. 
Lowell was placed across the bed. A sheet was put round the well 
limb, and a towel tied round the knee of the lame one. Several 
persons took hold of the sheet, and several hold of the towel, ex- 
tending in contrary directions. The limb pointed off in an awk- 
ward position. They first extended it, and then carried it in toward 
the other. Dr. K. had hold of the end of it by the ancle, carrying 
it in : Dr. I. was feeling for the head of the thigh bone. — When I 
first came, 1 found Dr. K. trying to set the limb. — When Dr. I. arriv- 
ed, he first examined the hip ; had some conversation with Dr. K. ; 
went out a short time with him and returned. The examination was 
not more than four or five minutes. Lowell inquired of Dr. I. 
respecting his situation. Dr. I. answered, that he thought the hip 
bone was dislocated, and the socket a little fractured ; and said, 
that they would set it ; to this Dr. K. assented. They were not 
more than ten or fifteen minutes about it. They*then said it was set, 
and well set. Dr. I. assisted occasionally in taking hold of the 
end of the limb and the towel and bearing in towards the well limb. 
After this they put a handkerchief round both limbs. I saw no dif- 
ference in the length of the limb. Dr. K. said, Lowell must lie here 
three days. Dr. I. said, " Three days ? you must lie there three 
times three ; you must lie fourteen days." Lowell asked I. if it 
would not be necessary for him to come over next morning. Dr. 
I. said no, that Dr. K. would be there, and he would give him par- 
ticular charge how to proceed. Dr. K. was then in another room. 
When he returned, Dr. I. told him that he must bleed him next day ; 
for he had not bled very well ; and said something about medicines. 
Dr. K. and Dr. 1. both said that Lowell was doing very well, and 
would not be detained from business but a short time. — Dr. K. called 



116 

next day and was in occasionally, and frequently at first ; I was not 
knowing to his making any examination. He prescribed and brought 
liniments.- — Lowell was in great pain, especially the fourth or fifth 
day ; and complained and said he was afraid his hip was not set. 
On the 5th or 6th day I sent over by Mr. Brooks to tell Dr, I. that 
my brother was in great pain, and wished him to come immediately. 
He came on the fifteenth day after the operation. Lowell kept 
confined to his bed fifteen days after the injury. He got up immedi- 
ately before Dr. I. came, to have his bed made. He rested on my 
shoulder and the bed post while it was made. I was not present 
at the interview. Dr. I. sent medicine soon after his return, and 
at one other time. He kept his bed three days after that ; making 
eighteen days. Ten days after this (1st of October), Dr. I. came 
the third time. He was not sent for at this time, to my knowledge. 
I was present. I had hired another person to take care of the 
store, and attended exclusively on my brother. This time Mr. 
Lowell stood up and rested on my shoulder, and asked Dr. I. the 
cause of-the hollow of his hip. Dr. I. did not examine it. It was 
apparent outside of his trowsers. Dr. J. said it was A natural con- 
sequence, and when he gained strength it would fill up. Dr. I. 
said he was doing well ; that his case was an important one ; 
every thing was right then, and he would not be detained from 
his business more than a few weeks ; but that he must be careful ; 
it would be better that his house should burn down about his ears, 
than that he should make one misstep. Dr. I. told Lowell to write 
to him ; and he would come or send medicines. He took hold of 
the limb and swung it, and said it was all right. I saw no compari- 
son of the length of the limb. This lasted five or six minutes. 
He appeared to be in a hurry. — On the 23d of October he came 
over a fourth time, and tarried then but a short time. When he 
came, he observed, that he wanted to ask my brother a few ques- 
tions. My brother said he wished to ask a question. " What is 
the cause of the difference in length between the limbs ?" I. did 
not make an immediate answer ; he waited for some minutes; and 4 
said, it looked as though it was not set ; that he was in a great hurry, 
and would be over again next day. His observation was, either that 
it looked as if it was not set, or was not in its place ; and said, " To- 
morrow I will come and give it a thorough examination." — Next 
time, eight or ten days after, saw Dr. 1. at Eastport, about the 3d of 
November ; I told him my brother was anxious to see him ; that he 
was in considerable pain. I. said he was so driven that he could 
not possibly leave ; but he said that he would come over that after- 
noon. I asked him his opinion ; he said he was afraid the bone was 
not set. He said, that he would come over that afternoon, unless 
the witches prevented. He came over on the 19th of November, 

with Dr. . I was not present. 

Mr. Lowell's family was absent at this time. I attended on my 
brother carefully. The length of the limb and appearance continued 
the same ; we did not discover the increased length till the 23d of 



117 

October. The injured leg, very soon after the dislocation, con- 
tracted, and my brother complained of pains in his hamstrings. 
This took place within a few days, and before he left his bed. 
He lay crooked up in bed with the bandage on — the limbs eight 
or ten inches apart — as to this I am not quite positive. The 
operation was performed in a small room. 1 saw no comparison 
of limbs at that time. After the operation I went to the boat. 
I. said K. was an old quack ; that he was not fit or he would not 
trust him to doctor a goose, or something to that amount.- I did not 
recollect this on the former trial, nor in giving my deposition. 
It arose in my mind after hearing Winslow. — The witness being 
questioned concerning the first operation performed by Dr. I., stated 
that the plaintiff was laid lengthwise of the bed ; a ball of cloth 
was placed between the thighs ; the injured limb was carried out ; 
and the ball served as a fulcrum for the leg to pry over, and be 
made use of as a lever. Dr. K. worked some time, and said he 
believed it was set, and asked me if I did not think it was not. 1 
said I could not tell. Coffin said he thought it was not ; and ad- 
vised to send for Dr. I. Coffin and I went in another room, and 
he advised me to send for Dr. I. I asked him why he did not 
advise Dr. K. so. We went into the room where my brother was 
and asked him about it. He mentioned it to Dr. K. and the Doctor 
consented to it. 

Cross Examination. — The plaintiff lived at Lubec, near Dr. K. 
Dr. K. was his family physician. After Dr. I. and Dr. K. consulted, 
Dr. K. asked what part he should take in the operation ? Dr. I. 
answered, " What part would you like ?" Dr. K. replied, " A second 
hand's birth." Several persons assisted. Dr. I. directed. Dr. K. 
took hold of the foot. Dr. K. called frequently ; he called two 
or three times a day for several days. The plaintiff was moved into 
another house before the 23d of October. I never testified this 
before. He was moved by walking ; and went considerable distance. 
My brother made no complaint of Dr. K. ; but said that he had 
never examined. When the operation was performed several ob- 
served there was a grating. Dr. I. said that was the noise of the 
bone going into the socket. Dr. I. asked my brother whether it 
felt easeir or more natural. He answered yes. 

I did not hear my brother ask Dr. I. to attend further, nor request 
him to attend as a physician. He proposed to send a boat. Dr. I. 
never came with Dr. K. ; always alone. Dr. K. did not make 
any new engagement. 



I, Josiah Coffin, of Campobello, in the County of Charlotte, 
Province of New Brunswick, of lawful age, do testify and say, that 
I was at Lubec in September, 1821, near Charles Lowell, when he 
fell from a horse; received a bad injury of the hip by the horse 
falling on him. I helped carry him into the house ; was* present and 



118 



assisted when Dr. K. operated upon him ; after which it was 
thought best to send for Dr. I. ; he came over as soon as pos- 
sible, considering the distance and badness of the ferry from East- 
port to Lubec — I think in about two or three hours. After Dr. 
I. examined Mr. Lowell's hip ? he took Dr. K. into another room; 
in a few minutes they returned, said Mr. Lowell's hip joint was 
out, and the socket that received the head of the thigh bone was 
fractured, and Lowell must suffer another operation. — Dr. I. order- 
ed preparations to be made, and proceeded to operate on Lowell, 
and I assisted as directed. — Dr. K. assisted with others. Dr. I. 
gave directions and took his stand to manage the head of the 
bone. After some exertions of Dr. I. with our assistance, Lowell 
said that he felt the bone go into its place. Dr. I. said he felt it go 
into its place, and told us to give back ; then asked Lowell if he 
did not feel more free from pain ; Lowell said he did ; then I. and 
K. examined the hip. I. took hold of the injured limb, raised it up, 
and turned it in ever}' direction with ease ; it appeared to move 
easy without giving him pain. Lowell said it felt natural ; but 
before I. operated, the injured limb stood in an unnatural position, 
standing outward from the other, and could not be carried inward 
without giving Lowell great pain ; but it appeared at this time in 
its proper place. I. saw I. and K. take hold of his knees ; but I 
saw no difference in the length, but both legs were of a length for 
any thing that I saw. Both I. and K. pronounced the bone set. I. 
was very minute in his directions — told Lowell that it was different 
from simple luxation ; that the bones that formed the socket were 
fractured ; that they must have time to unite ; told Lowell that much 
depended on his taking good care of himself; that he feared that 
he would be a cripple for life — that he expected that he would be in 
much greater pain five or six days hence from inflammation ; and 
that it could not be helped ; that he should advise Dr. K. to make 
use of such means as was in reach of medical aid to keep back in- 
flammation, and bleed him again next day; that he would send 
medicines over by the boat, if Dr. K. requested it. I am confident 
that Mr. Lowell's housekeeper was not in the room after the bed 
was fixed, but she handed at the door sometimes such things as were 
called for ; but Joshua Lowell generally went for what was wanted. 
Mr. C. Lowell asked Dr. I. to attend him. Dr. I. said that he 
had a large number of sick at Eastport, that were depending on him 
constantly, which rendered it impossible. Lowell spoke about 
sending a boat for I. the next day ; which I. replied that, if 
his business would admit he would come ; but told Lowell that he 
could not attend him, and desired him not to depend on him, for he 
did not know that he could come at all ; he did not think it neces- 
sary for him to come over, as Dr. K. was on the spot, and could 
come in at any time ; that there was not much to be done ; told Mr. 
Lowell he must keep still ; the case ought to be left mostly to nature, 
as the thigh bone was in its place ; and as the fractured socket was 
as well as the nature of the case would admit of, or words to that 
effect. 



119 

From twelve to eighteen days after the injury, I was present when 
Dr. I. examined Lowell's hip. Lowell asked him why he did 
not come over when he sent for him ; he replied that he was very 
busy and had many sick to attend, but at the time you sent for me 
I was engaged in midwifery. Mr. Lowell told Dr. I. that he 
had a fit, and was afraid that he had got the bone out of its place ; 
he then got off from the bed by the help of me ; then Dr. I. 
examined his hip. Lowell asked the reason of a hollow at the out- 
side of his hip. Dr. I. said that his socket bone being fractured 
caused pain, and would for sometime, but when he gathered strength 
the hollow would fill up, but he did not see any thing but he was 
as well as the nature of the case would admit of. 

Question by the Plaintiff. That evening or at any other time did 
you hear Dr. I. say, that if he had not come to me I should 
have been a cripple for life, and that it was a pity there was not 
some living spectacle of Dr. K's ignorance and quackery, or words 
to that effect ? 

Answer. I do not recollect if it was, I do not recollect it. 

Question by the same. Do you know that Dr. I. demanded 
the payment of his bill for services in this very case at ten o'clock 
at night on board the packet when he found that I was going to 
Boston to see Dr. Warren ? 

Answer. I do not. 

Question by the same. When you left my house on the evening 
of the operation by Drs. I. and K., who remained in the room with 
me? 

Answer. I do not know, I believe there was two or three. I 
believe Mr. Stearns, Mr. Sumner, and Mr. Bigelow. 

Question by the same. Who was present when Dr. K. and 
I conversed that evening, as you have stated above ? 

Answer. I could not say all that was there. I believe Mr. 
Stearns, Mr. Sumner, and Dr. K. was there. I do not know but 
your brother was there. 

Question by the same. Who went from my house that evening 
in company with you ? 

Answer. I think it was John Winslow. 

Question by the same. Where was Dr. I. at that time ? 

Answer. I do not recollect whether Dr. I. was there or not, 
when T came away from the house. 

JOS1AH COFFIN. 



120 



No. II. 



Jotham G. Reynolds deposed, that he was the owner of the horse 
on which Lowell was riding, and was present when he received 
the injury. Lowell fell on his back; the horse fell obliquely across 
his thighs, and other parts of his body, so that his weight was more 
on one hip than the other. 



There is a slight variation in the report of this testimony; as contained in the 
pamphlet of the plaintiff it is as follows. 

• I, Jotham G. Reynolds, of Lubec, in the county of Washington, 
do depose, testify, and declare — 

Question by Charles Lowell, plaintiff. — Were you the owner of 
the horse by which I got hurt, in 1821 ? 

Answer. — I was. 

Ques. by same. — Were you present when I received the injury ? 

Ans. — I was. 

Ques. by same. — Did I fall on my back, or side ? 

Ans. — It appeared to me, you fell on your back. 

Ques. by same. — As 1 fell, did the horse fall directly across my 
thighs ? 

Ans. — It appeared to me, at the time, that the horse fell obliquely 
across the thighs and other parts of the body, and it appealed to me, 
thai the horse fell partly betwixt the legs, so that his weight was more 
on one hip than on the other. 



No. III. 



The following extract from the Address of the Attorney for the Defendant, will 
give an idea of its style and manner. 

I 

If any thing could add to our perplexity on this occasion, it would 
be to consider the determination with which these learned gentlemen 
undertook to put this poor plaintiff so resolutely to the rack, upon 
the strength of this precipitate and ill advised opinion. It is true, 
Dr. Townsend says, they thought there was no great chance for him. 
And Dr. Mann declares it to have been their unanimous opinion, 
that the attempt would prove unavailing. It was on this groundless 
supposition, and when there was so little prospect of success, ac- 
cording to their own avowal, that they undertook to put it to the test. 
What with their warm baths and smart cathartics, profuse bleeding, 
nauseating doses and preparatory drenches to relax the muscles, and 



121 

then sheets and cords and bandages and pullies, with the whole ac- 
cumulated force of the mechanical powers employed to wrench his 
limbs, according to Desault's most approved method of reducing 
luxations, until the head of the bone was fairly lifted from the socket 
it was thought to have formed — the agonies endured by Lowell 
under this operation could scarcely have been less than those of 
Damiens, for his attempt to assassinate Louis the XVth ; for there 
is a point beyond which human anguish cannot extend, and at which 
a merciful insensibility commences. An account of the execution of 
Damiens, found in the French Philosophical Dictionary, is as follows : 
He arrived at the Place de Greve at a quarter past three, regarding 
with a dry and steady eye the spot and instruments assigned for his 
execution. After some painful preliminaries, as well to be omitted, 
they proceeded to the business of dismemberment. Four powerful 
young horses, which had been provided, made incessant efforts for 
the space of fifty minutes to tear his limbs from his body, without 
being able to effect the object. At the end of this period, he being 
still alive, they were obliged to make use of their instruments to 
separate the joints, as had also been done in 1610 in the case of 
Ravaillac. He breathed a few minutes after the thighs were re- 
moved ; and it was not until his arms were amputated, that he gave 
up the ghost. This operation lasted, from the time he was placed 
upon the scaffold until he ceased to palpitate, nearly an hour and a 
half. 

How long the present experiment was continued, or how often it 
was repeated, or the patient fainted under the operation, does not 
appear from the depositions. His own courage, it seems, was un- 
exhausted. Why, then, with all this prodigious power employed, 
why was not the dislocation reduced ? For this plain reason ; be- 
cause no dislocation existed. Simply, because the thing was impos- 
sible ; there was nothing to reduce, The wonder is not that the 
operation was not successful ; the only wonder is that the plaintiff 
survived it. If the plaintiff had suffered any real injury, at the time 
he brought his action, from ignorance or unskilfulness, to whose 
hands is it to be attributed ? By their own statement these depo- 
nents persevered in performing the operation, which Dr. I. had 
declined to undertake, until it was proved to be perfectly impracti- 
cable. The presumption, therefore, is at least equal against any 
dislocation : the burden would certainly be upon them to prove that 
one existed ; and if the plaintiff had been advised to prosecute this 
formidable phalanx, for thus violently undertaking to set a limb, 
that did not prove to be out of its place, — upon this authority, upon 
this reason, and on this evidence, what could have been their de- 
fence — and what could have protected them against a verdict, ex- 
cepting the charitable supposition, that they must have been under 
some strange planetary influence or infatuation ? 

16 



122 



No. IV. 

Interrogatories proposed to John C. Warren, James Mannv 
Thomas Welsh, David Townsend, and Robert Hewes, by the 
plaintiff: 

Question 1st. Did you make an attempt last December to set or 
replace the head of my thigh bone, which had been displaced from 
its socket ; or were you in consultation on my situation, previous to 
any operation in your presence on me ; or were you present, or did 
you take any part in an operation for the above purpose ? 

Question 2d. Who were the persons with whom you consulted ? 
Question 3d. What was their opinion of my then situation and 
real injury ; and were they unanimous in that opinion ? 

Question 4th. Did their opinion coincide with yours ; and what 
was yours, and is your opinion of my case ? 

Question 5th. If a surgeon should undertake to set a dislocated 
limb of this kind, and should use no greater force than could be 
applied with the naked hands, without any thing fastened about the 
parts, to enable them to hold on, &c. ; and should not succeed at all, 
would you say that he used the means, or acted with the skill and 
management, that a surgeon ought? 

Question 6th. Before a surgeon should give up in such a case, or 
say that the limb was set, when it was not, ought he not to bleed the 
patient, or use other means of relaxation, and then make another 
effort ? 

Question 7th. If the limb in the case like the above, hung off 
from the body in a very awkward and unnatural position, and could 
not be moved in towards the other limb, without appearing to give 
extreme pain, ought not a surgeon of common or ordinary skill, to 
know from that circumstance, as well as from the circumstance of the 
injured limb being three inches longer than the other, that it could 
not be in its proper place ? 

Question 8th. Is not the return of the thigh bone to its original 
socket usually accompanied with so loud a noise, that it must be 
heard by all in the room, and could not be mistaken, especially by a 
prudent and discerning surgeon ? 

Question 9th. Would not a common caution and attention re- 
quire the attending surgeons to examine the limb occasionally ; es- 
pecially if the patient should complain of much pain, long after the 
injury? 

Question 10th. Would not a surgeon* of common and ordinary 
skill and care have compared the length of the injured limb with that 
of the other ? 

Question 11th. Is it not a general rule, that an injured limb Like 
the abovenamed, being several inches longer than the other, is an 
indication that such limb is not in its proper place ? 

Question 12th. In attempts to set and reduce a dislocated limb 



123 

of this kind, is not a fulcrum, or something to answer its purpose, 
necessary ? 

Question 13th. If a person, whose hip or thigh bone was dislo- 
cated, as mine is, and set in three hours after the injury, should lie 
on his back fourteen days without turning, having his knees tied 
together, would it be in his individual power to get the bone out of 
the socket again, while in that situation ; or to make the necessary 
extension of the limb to lodge the head of the thigh bone three inch- 
es below the socket, where mine is ? 

Question 14th. Is not the natural action and re-action of the 
muscles and cords about the hip, such as to require something of a 
relaxing nature, and a powerful force to be applied in order to ex- 
tend the limb three inches, or even one inch, beyond its natural 
length ? 

Question 15th. If it were possible for one in the situation de- 
scribed in the thirteenth question, to get the bone out of the socket 
again, would not those strong cords and muscles immediately con- 
tract and draw the limb up, instead of causing such an extraordinary 
extension as to make it three inches longer ? 

Question 1 6th. Is my case any thing more than a simple luxation ? 
Question 17th. From your examination of my case, do you think 
that the head of the thigh bone of my injured hip or thigh is lodged 
in the ischiatic notch ? 

Question 18th. Would it not be necessary to extend my leg con- 
siderably in length before the head of my thigh bone, last named, 
could be removed from its present lodgment? 

Question 19th. In December, 1821, did you make an attempt to 
set or replace the head of my thigh bone, which had been .dislocated 
from its socket by a downward luxation ? 

Question 20th. Did you then, or do you now, consider my case 
any other than a simple luxation ? 

Question 21st. When the hip is disjointed, is not the difference 
in the length of the injured limb and the well one so great as to be 
a visible and decisive proof of dislocation existing ? 

Question 22d. If two surgeons were called in to see a person 
whose hip had been disjointed only two or three hours before, and 
they should operate — say that they had set the bone, and should 
subsequently attend the patient for the space of six or seven weeks, 
and in that time the patient should repeatedly tell them that he was 
in great pain, and that he feared something was wrong ; and they 
should at their several visits say that all was right, and that he was 
doing well, — but it should eventually prove that the bone was all 
the while out of joint, would you not say, that it was a strong mark 
of gross ignorance, or inattention on the part of the surgeons, that 
they had not discovered the true situation of the limb before ? 

Cross Interrogatories put to John C. Warren, M. D. and the 
other deponents on the part of the Defendants. 

Interrogatory fir st. What is your profession or business, and how 
long have you been engaged in it ? 



124 

Second. Have you ever reduced a luxated hip joint? and how 
many? did you ever see a downward and inward luxation of the 
hip joint? did you reduce it? did you ever know any one reduce 
such a luxation ? 

Third. Do you know Charles Lowell, of Lubec ? if you do, 
please state how, and when you became acquainted with him ? 

Fourth. Was Lowell's hip joint dislocated when you saw him — if 
so, what were the reasons that induced you to think so ? Please 
state particularly and minutely all the facts and appearances respect- 
ing it ? 

Fifth. Do you not think it possible you may have been in an 
error in your opinion in the case ? 

Sixth. Have you never before in the course of your professional 
practice made as great a mistake as it would be to pronounce Low- 
ell's hip joint dislocated when it was not ? 

Seventh. Do you not consider Lowell's case of such a nature as 
that medical men of high standing in the profession would be likely 
to differ in opinion respecting its present situation, or at the time 
you saw him ; that is, whether it then was or now is dislocated or 
not? 

Eighth. Would not a luxation of the joint, or fracture of the 
lower edge of the acetabulum, the necessary violence done to the 
parts in producing these and replacing the bone, together with a 
consequent rheumatic affection of the limb, hip, and pelvis, attended 
with some distortion, particularly of the latter, be alone sufficient to 
account for all the appearances in Lowell's case, when you saw him, 
without supposing the head of the bone out of its proper socket ? 

Ninth. May not the soft and bony parts about the hip joint, 
especially in a muscular man, be so injured as to render it impossible 
for the most competent surgeon, some months after the injury, to 
judge what was the actual situation of the patient, or what ought to 
have been done for him at the time of the injury ? 

Tenth. Did you make any attempt to relieve Lowell's disability ? 
if so, what were the means made use of, and what was the result ? 
Please to be minute and particular. 

Eleventh. Do you consider dislocation pullies necessary in re- 
ducing luxations of the hip joint ? what proportion of cases can be, 
or are reduced without them '■ do not medical men differ in opinion 
with regard to their being used at all ? and have you never known 
or heard of a case or cases being successfully treated by the hand 
after the pullies had failed ? 

Twelfth. Have you never known a case of dislocation where the 
surgeon first called, declared the pullies necessary to reduce it, and 
while preparations were making therefor, another man stepped in 
and reduced it by hand ? and who was the surgeon first called in the 
case ? 

Thirteenth. Do you think any blame should attach to a surgeon 
for not using the pullies, when he succeeded perfectly' well in re- 
ducing the dislocation without them ? 



125 

Fourteenth. If you are of opinion that Lowell's hip joint is now 
out of place, do you not deem it possible that it might have been 
reduced at the time of the original injury, and afterwards displaced 
by accident or misconduct of the patient, and this done without the 
knowledge of the surgeon, and without his being able to prove the 
fact in a Court of Justice ? 

Fifteenth. Is it customary for a surgeon after once reducing a 
luxation, to watch the patient night and day to prevent such accident 
or misconduct, or to take with him in his visits a credible witness to 
prove the correctness of his own conduct, and guard himself against 
the malice and intrigue of a litigious patient ? 

Sixteenth and Seventeenth Interrogatories in the original, crossed 
out. 

Eighteenth. What weight would you give to the opinions of com- 
mon people standing by or assisting to reduce a dislocated hip, as to 
the professional skill with which the operation was performed, or are 
people in general competent to describe the means used by a surgeon 
to reduce a dislocated hip ? 

Nineteeth. What is Robert Hewes's character as a surgeon ? 

Twentieth. Do you know any other matter or thing advantageous 
to the Defendants, or either of them ? if so, please to state the 
same as particularly and minutely, as if thereto specially interro- 
gated. 

John C. Warren, of said Boston, Doctor of Medicine, to the said 
several interrogatories and cross interrogatories, doth testify, depose, 
and say : 

1. To the first he saith, that in December last, he did make an 
attempt to replace the thigh bone of Charles Lowell, the person here 
present ; this was done at the Massachusetts General Hospital. I 
did enter into consultation with several gentlemen upon his situation, 
previous to any attempt being made to replace the dislocated bone, 
and took a principal part in that operation. 

2. To the second he saith, the persons with whom he consulted 
were Doctors Townsend, Welsh, Mann, and Spooner, Consulting 
Physicians of the Hospital. 

3. To the third he saith, that they were unanimously of opinion 
that the hip was dislocated. 

4. To the fourth he saith, that their opinion did coincide with that 
of this deponent. His opinion then was, and still is, that the hip was 
dislocated. 

5. To the fifth he saith, that it is difficult to give a precise answer 
to this question, on account of the generality of its terms. This 
deponent has heard of cases in which manual force only has been 
applied with success. But he is of opinion that in case a surgeon 
should use manual force only, and know that it did not succeed, such 
surgeon could not be said to have acted with proper skill and man- 
agement, and used due means to reduce the dislocation, if he applied 
no further force than could be applied by the naked hands. 

6. To the sixth he saith, certainly he should. 



126 

7- To the seventh he saith, the circumstances enumerated in the 
question, would lead this deponent strongly to suspect that the limb 
was out of its place ; but he should not consider these indications 
decisive. 

8. To the eighth he saith, it frequently happens that such a noise 
is heard, but not uniformly, when the bone is restored to its socket. 

9. To the ninth he saith, that if the patient should remain appa- 
rently without much pain, he should not consider such examination 
necessary ; but if the patient should complain of much pain, and for 
a considerable time after the injury, he should think such an exami- 
nation ought to be made. 

10. To the tenth he saith, Yes. 

11. To the eleventh he saith, that the circumstance of the limb 
being three inches longer than the other, is an indication that the 
limb is disordered, but is not a necessary indication of a dislocation 
of the bon^». It might proceed from two other causes ; either from 
a fracture of the neck of the bone, with a relaxation of the muscles, 
or from a simple relaxation of the muscles. 

12. To the twelfth he saith, that it is generally necessary, but is 
not in all cases indispensable. 

13. To the thirteenth he saith, that in his opinion it would not be 
in the power of the patient to displace the bone., under the circum- 
stances stated. 

14. To the fourteenth he saith, that the structure of the part is 
such as to require great force to extend the limb one inch beyond 
its natural length. 

15. To the fifteenth he saith, that it would depend upon the di- 
rection in which the head of the bone should be forced out of its 
socket. H forced downward, the limb would be extended ; if up- 
ward, it would be shortened. 

16. To the sixteenth he saith, that he has no reason to think that 
it is. 

if.. To the seventeenth he saith, that that is his opinion. 
18. To the eighteenth he saiih, No. 

1. To the first cross interrogatory, put on the part of the Defend- 
ants, he saith, that his profession and business is that of a physician 
and surgeon, in which he has been constantly engaged for the last 
twenty years. 

2. To the second he saith, that he hath frequently reduced a lux- 
ated hip joint ; the number of instances he cannot recollect. He 
does not recollect ever to have seen a downward and inward luxa- 
tion of the hip joint. 

3. To the third he saith, that he saw Mr. Lowell for the first time 
some time during the last winter ; the precise time he cannot tell. 
The place was Clark's Tavern, in this place. He was removed in 
the course of a fnw days to the Hospital, during which time the de- 
ponent saw 7 him several times. 

4. To the fourth he saith, that in his opinion, the limb was dis- 
located at that time, and his reasons for believing so, were, first, that 



127 

the knee hung out from the other in an awkward and unnatural 
manner; secondly, that the thigh of the injured side was longer than 
the other, or in other words, that the knee projected lower than the 
other; thirdly, that the flexor or hamstring muscles were contracted, 
so as to keep the leg continually bent ; fourthly, that the trochanter 
major was not to be felt in its proper place ; fifthly, that -the head of 
the dislocated bone could be felt in an unnatural position, in or 
about the ischiatic notch; sixthly, that the patient had not a free 
and natural use of the limb, but its motions were constrained in such 
a manner as happens only in the case of a dislocated limb, by the 
head of the bone being lodged in the ischiatic notch; that is, in a 
dislocation backward and downward. The dislocation of Mr. Low- 
ell, in the opinion of this deponent, was one of that character. 

5. To the fifth he saith, be doth not. 

6. To the sixth he saith, that he doth not recollect any. 

7. To the seventh he saith, that it was a dislocation difficult to 
discover ; but one about which, in his opinion, men of high standing 
in the profession could not differ. 

8. To the eighth he saith, that he thinks the appearances in Mr. 
Lowell's case could not have been produced by auy or all of the 
circumstances enumerated in this question. 

9. To the ninth he saith, yes, such a case may exist. 

10. To the tenth he saith, that, as before stated, he did make such 
an attempt ; the means were these : the patient was placed upon his 
right side and secured to a table, and further secured to a neighbour- 
ing wall by a sheet passed between the thighs, and a force was 
applied immediately above the knee of the injured limb, in a direc- 
tion to draw it forward and inward. At the same time a force was 
applied at about the middle of the thigh, at right angles with the 
limb, in such a direction as to draw the head of the bone toward the 
socket. The forces were gradually and alternately increased for 
the space of about an hour, and till all prospect of success was at an 
end. The force at right angles was applied by pullies, and the other 
by the strength of several persons by means of bandages and cords. 
By way of preparatory measures, the patient took a powerful cathar- 
tic in the morning, and went into a warm bath. And in order to 
relax the muscular powers more fully, immediately before the opera- 
tion he took nauseating doses of tartrate of antimony, and was bled 
as freely as possible. 

11. To the eleventh he saith, that he doth consider them neces- 
sary, though not indispensably so ; the greater proportion of cases 
can be, and are reduced without them. There is some difference of 
opinion with respect to their use, though the most celebrated authors 
decidedly recommend their use. He has never known a case treated 
successfully by the hand after the use of pullies had failed. 

. 12. To the twelfth he saith, he hath never known such a case. 

13. To the thirteenth he saith, that he should not. 

14. To the fourteenth he saith, that if the dislocation, had been 
reduced, he should think it possible the bone might be thrown out 



128 

of its place again, by the application of considerable force, or the 
use of considerable motion of the limb, soon after the reduction. 

15. To the fifteenth (objected to with the three following as above) 
he saith, No. 

16. To the sixteenth he saith, that, in his opinion, a surgeon, who 
employs the best means in his power, ought not to be responsible in 
damages ; and that a surgeon who has opportunity to examine a case 
of dislocation, immediately after the injury, other circumstances 
being equal, has better means of judging of the nature of the case, 
than one who examines the case several months afterwards. Still 
he is of opinion that the case may be such, that it may be quite 
apparent, several months afterwards, what the real nature of the 
injury was. 

17. To the seventeenth he saith,. that not having had a distinct 
account from Dr.* I. himself, of the mode of treatment practised 
in Mr. Lowell's case, he does not feel qualified to give an opinion on 
his practice. 

18. To the eigthteenth he saith, that he should attach no import- 
ance to the opinions of persons thus situated, as to the professional 
skill with which an operation was performed ; but he thinks that 
intelligent persons, without professional skill, might describe with 
sufficient accuracy the visible means used in the operation. 

19. To the nineteenth he saith, that the said Robert Hewes has 
some reputation for reducing dislocated limbs. 

20. To the twentieth he saith, that he knows nothing more, unless 
it be material chat the letter hereto annexed, dated April 12, 1822, 
marked A, was written by this cleponent at the time it bears date, and 
forwarded according to its direction. This letter is hereto annexed 
(the said Lowell objecting thereto) at the request of A. Peabody, Esq. 
representing Dr. I. At the time of writing that letter, as far as 
this deponent can recollect, he was not aware that any judicial pro- 
ceeding was pending on the subject. 

JOHN C. WARREN. 

Note. — On reviewing my deposition, I find myself not altogether satisfied 
with the degree of precision in the expressions of some parts of it; and en- 
deavouring to recall to memory the reasons that might have prevented me 
from giving it. that attention, which, since the formidable criticism to which 
it has been exposed, might be thought to have been required, they seem to 
be nearly these — When I was called on to give this deposition, I did it 
under the impression that there would not be any important question as to 
the anatomy or surgery of the case. It would turn, as I thought, and 
still think it should, exclusively on the charge of negligence. My depo- 
sition 1 regarded, therefore, as a mere matter of form. No part of the 
deposition was written by me, but by the commissioner ; nor did I myself 
read it over after it was written. Finally, the period of the examination 
was more than two years from the accident ; and I was called suddenly 
to answer questions on points, most of which had not entered my mind from 
the time I saw the patient till that moment. These facts will, I hope, with 
every candid mind, form my excuse, if any be required, for a want of exact- 
ness in the language of the deposition. For illustration, I will furnish an 
instance of the description alluded to. Being asked, whether I had ever 



129 

reduced a dislocation of the hip joint, answered, that I had reduced a 
number, but could not recollect how many. The defendant's attorney, 
adverting-, in his manner, to this answer, said, that I " was not able to charge 
my mind with the number ef cases," or words to that effect ; obviously 
meaning' to intimate, that the number of hip dislocations I had reduced, 
was not likely to be worthy of consideration. Now any reflecting person 
will perceive at once, the impossibility of my having been able to answer 
suddenly, and without previous consideration, what number of cases of this 
or any other dislocation I had in the course of practice reduced. Since 
his publication I have been necessarily led to ascertain, as nearly as possi- 
ble, what number of cases of hip dislocation I have seen ; though I would 
by no means aver I have recollected the whole number. 



No. V. 

LETTER TO DR. I. 

Boston, April 12, 1822. 
Dear Sir, 

In reply to your letter requesting my opinion on the question, 
whether Mr. Lowell's dislocated thigh had been reduced, I beg leave 
to say : 

First — That every person will understand it to be impossible for 
me to say positively, that the limb was not reduced, provided es- 
pecially there is any positive testimony that it was so. 

Second — That my opinion certainly was, that the limb had not 
been reduced, for the following reasons. 

1st — That if it had been reduced, it would not have been again 
luxated without great violence, on account of the depth of the sock- 
et ; and I did not understand that any such violence was inflicted 
after the efforts to reduce it. 

2d — That this dislocation is so difficult to reduce, that I presumed 
it would remain unreduced often in the hands of the best surgeons, 
and with the best means. If such a case were to come to me, I 
should have many doubts of being able to reduce it in a muscular 
man, even in its most recent state, especially without dislocation 
pullies. 

For these reasons my opinion was, that the dislocation which was 
thought to be reduced, was not so, in fact. I would not, however, 
oppose an opinion to any positive testimony. 

In aDy case, I presume that no blame is to be attached to you, as 
the case is a very difficult one, the worst of four kinds of dislocations 
of the hip, and 1 presume, also, that you did every thing that circum- 
stances admitted. 

I am, Sir, your very obed. servt. 

J. C. WARREN. 

It may be a question, whether the acetabulum had been fractur- 
ed ; but as time enough for it to unite had elapsed when I saw him, 
I can give no opinion on this point. 

17 



1 30 



Deposition A. 

\ t A , testify and say, that in the month of June, m 

the year 1822, I examined Charles Lowell, then at Eastport, re- 
specting an injury of his hip, which he stated to have happened the 
fall before. My examination was lengthy and critical, and my opin- 
ion then was, that the thigh bone was not out of joint ; and I have 
not altered my opinion since. From the nature of the injury as 
described to me by the said Lowell, it could hardly be possible that 
the hip should be dislocated. A fall on the hip, with the weight of 
a horse upon it, would be likely to break the bones of the pelvis, 
and might drive the head of the bone through the bottom of the 
socket, but could not dislocate the joint £ and, in my opinion, if 
there is any derangement of the bones, it is a fracture, and not a 
dislocation. In that case, it would not have been in the power of 
Dr. I. or any other medical man to have rendered the said Lowell 
any effectual assistance, more than to have administered remedies to 
keep down inflammation ; they could not have altered the situation 
of the bones. As for the apparent lengthening of the affected limb, 
I think that is owing to the preternatural contraction and relaxation 
of the muscles situated about the hips ; and is made to appear so by 
the twisting of the bones of the pelvis on the spine. Any person^ 
when sitting in a chair, can, by an exertion of the muscles, make 
one knee project beyond the other, as much as Lowell's did when I 
saw him. The same lengthening of the limb takes place in a dis- 
ease of the hip, called the hip disease, which partakes of the nature 
of white swelling, where no external violence has been received. 
It is difficult to determine in case of injuries of the hip precisely 
what the injury of the bones is ; but it has frequently happened, 
within my knowledge, that by a fall directly on the hip joint, though 
the bone was not dislocated, as was evident by the natural position 
of the foot and limb generally, and from its being moved by the 
hand of the surgeon in all directions, yet the patient has never re- 
covered from his lameness ; and in several instances they have 
never been able to walk afterwards. In cases where the thigh bone 
is dislocated backwards, and the head of the thigh bone rests on 
the back part of the broad hip bone, the limb will be a little short- 
ened, and the foot will point towards the other foot, and cannot he 
turned outward in the least. In case the head of the thigh bone 
should be lodged in the ischiatic notch, so called, the limb would or 
might be a little lengthened ; but the foot would be turned pointing 
towards the other foot, and could not be turned outward in the least. 
Both when the head of the bone is on the back of the hip bone, and 
when in the ischiatic notch the head of the bone ean be distinctly 
felt by the hand. When the head of the thigh bone is dislocated 
downwards, and rests in the thyroid hole, so called, the trochanter 



131 

^wHl be misplaced, and the head of the bone will be felt on the side 
of the perineum, between the scrotum and anus, and the foot will 
foe turned out. Very great violence done to the parts, and conse- 
quent swelling, might render it difficult to ascertain, by feeling, the 
position of the head of the bone soon after the injury ; but when 
the swelling had subsided, it might be ascertained by the touch. 
As to the length of time, which may elapse after a bone is dislo- 
cated, before it will be impossible to reduce it, it is uncertain, and 
probably may differ in different cases. But the time that a joint 
may remain dislocated, and yet admit of being replaced, is longer 
than has been generally supposed. I reduced a dislocated shoulder 
that had been out seven weeks, another that had been out nine 
weeks, and one that liad been out four yearly months. I should 
not think -that a hip joint, having been out of place six or even eight 
weeks, would render it impossible to reduce it. It might even be a 
more favorable time for the operation, than immediately after the 
accident, especially if the soft parts at first were much bruised and 
swollen. 

I do not think that the mechanical powers, such as the wheel and 
axle, or the pullies, are necessary to reduce a dislocated hip, or any 
other dislocation. They have sometimes been used with effect, but 
they have oftener been injurious ; and what can be effected with them, 
can be effected without them. It is not the quantum of force which 
reduces dislocated bones, so much as it is the direction of the force ; 
and this can be given by the hand of skill, better than by pullies, &c. 
In reducing the hip joint it cannot be done by direct pulling; but 
we take advantage of the thigh bone as a lever to move the head of 
the bone from the place where it may be lodged, and bring it into 
its former situation. In some cases the fulcrum is some of the 
bones of the pelvis ; in others we have to supply it by some external 
body. 

Question by Defendant's attorney. Did you ever reduce a dislo- 
cated hip ? And if so, please to state the manner. 

Answer. I once reduced a dislocated hip joint. It was dislocated 
upward and backward ; and after pulling it in every direction but 
the right, it was reduced easily by carrying the knee towards the 
patient's face. I had the assistance of two men only. 

Question by the same* Would the distortion of the pelvis, by 
contraction of the muscles, produce an apparent lowering of the hip 
joint, or a hollow up the hip ? 

Answer. It might, and probably would. 

Question by the same. If the head of the thigh bone were forced 
through the bones of the pelvis, would that produce, in any measure, 
the same effect? 

Answer. It would. 

Question by the same. Is the dislocation of the hip joint an un- 
usual occurrence? and might a skilful surgeon fail in any attempt to 
reduce it ? 



132 

Answer. A dislocation of the hip is very rare ; and probably not 
one medical man in ten would be able to reduce it. 

Question by the same. Would a failure to reduce a dislocated 
hip subject a man to the just imputation of ignorance in his profes- 
sion ? 

Answer. T should think not, for men of science, and reputed skil- 
ful, have failed. 

Question by the same. Do you know Dr. I. of Eastport? And if 
so, what do you think of him as a man acquainted with his profes- 
sion ? 

Answer. I have been acquainted with Dr. I., and think him 
above mediocrity in the knowledge of his profession, especially in 
anatomy. 

Question by the same. May not physicians and surgeons disagree 
in opinion respecting a disease of the hip, without the imputation of 
ignorance or negligence ? 

Answer. Men of science and skill have often disagreed in such 
cases. 

Question by the same. Were the head of the thigh bone lodged 
in the ischiatic notch in Lowell's case, how would the limb act ? 
Would it be as when you saw it at Eastport ? 

Answer. When the head of the bone is lodged in the ischiatic 
notch, the foot would be turned inward, which was not the case with 
Lowell when I saw him. 

Question by the same. What is the situation of the ischiatic notch 
in the living subject ? And is it filled or partially so, with any sub- 
stance ? 

Answer. In the living subject the ischiatic notch is filled with a 
firm strong ligament, which is again covered with muscles, so that 
the head of the bone could not sink much into it. 

Question by plaintiff's counsel. When you were at Eastport, be- 
fore you examined Charles Lowell, and while you were at some 
distance from him, did you say to any one, that Lowell's hip was not 
dislocated, or to that purport, and if so, to whom did you make the 
observation 2 

Answer. I do not recollect that 1 did, and am very confident 
that I did not. 

Question by the same. Did you tell Lowell he had better drop 
his action and try to get well, which would be better than to try to 
get damages of the Doctors ? 

Answer. I think I did. 

Question by the same. How long did you take to examine Low- 
ell's hip joint, and did you attempt in any manner to restore it to its 
proper place and appearance ? 

Answer. I did not measure the time, but put him in various 
positions, and examined him in company with Dr. B. till I was 
satisfied it was not out of joint. I did not make any attempt to re- 
place the bone. 



133 

Question by the same. What did you prescribe for the remedy 
of his limb, and what encouragement did you give him ? 

Answer. I believe I advised him to make an issue on his hip, 
and keep it open a long time. 

Question by the same. Did you tell him he would probably be a 
well man in a year, if he followed your prescription, or to that ef- 
fect, and did you give it to him in writing ? 

Answer. I think it probable that I gave him encouragement that 
he might get well, or better than he was then ; but do not recollect 
whether I gave him a written prescription or not. 

Question by the same. Had you heard Dr. I's. representation of 
LowelPs case before you saw Lowell ? 

Answer. I had. 

Question by the same. If there was a distortion of the pelvis so 
as to occasion the appearance of LowelPs limb, would it not have 
occasioned pain at or near the back bone ? 

Answer. I do not know that it would. In cases of disease of 
the hip joint, where the pelvis is distorted, the patient dees not com- 
plain of pain in the back to my recollection. 

Question by the same. If there were a dislocation of the head of 
the bone into what is called the ischiatic notch, would it not occasion 
the same appearance that LowelPs exhibited ? 

Answer. I think not. 

Question by the same. How do you account for the hollow ap- 
pearance in LowelPs hip, at the place where the head of the thigh 
bone was inserted, and did you feel it to be hollow when you exam- 
ined it ? 

Answer. I did not perceive any more hollow on the hip joint, 
than might be accounted for from the effect of the muscles, or a 
fracture of the pelvis. 



Deposition B. 

I, B , of St. Andrews, in the Province of New-Bruns- 
wick, Physician, of lawful age, on oath, do testify and say, that I was 
this day (June 13th, 1822) present at an examination of diaries 
Lowell of Lubec, for a disease or affection of the left hip joint, and 
am opinion that it does not arise from dislocation at present existing, 
but from affection of the muscles, or some other cause. 

Question by Plaintiff, Did you ever reduce and set a thigh 
bone which had been dislocated from its socket by a downward 
luxation ? 

Answer. I never did. 



134 



Deposition C. 

Dr. C. was introduced as a witness by the defendants, and 
was requested to explain to the jury the structure of the different 
parts of the subject, and to exhibit the varieties of dislocation by the 
bones of the skeleton (viz. the pelvis and thigh bone) which were 
produced for that purpose. This mode of proceeding was objected 
to by the plaintiff's counsel ; who proposed, in that case, to offer 
the plaintiff himself to the personal inspection of the jury. No op- 
position being made to the course by the defendants' counsel, the 
plaintiff was submitted to the examination of several of the ju- 
rors. Dr. C, exhibited the manner in which several dislocations 
took place ; viz. two forward, one of which were upward and one 
downward, and two backward, both upward. He indicated the po- 
sition of the ischiatic notch. In dislocation into that notch, he testi- 
fied, that the knee and toe turn in. It was impossible for the knee 
to turn outwards in a dislocation into the ischiatic notch. The plain- 
tiff's knee and foot are canted a little outward. Sir Astley Cooper 
was considered the greatest authority in surgery. The witness 
thought the plaintiff's injury was a fracture and derangement of the 
pelvis. The ischium might have been broken, and some tuberosity 
forced and felt about the notch. From the nature of this testimony, 
it is not capable of being perfectly reported. He testified to the 
respectable standing of Dr. I. in his profession. 



Deposition D. 



Dr. D. concurred in the opinion of Dr. C. and confirmed the 
general points of his testimony. It was an injury to the bones of 
the pelvis. A surgeon could be no benefit to Lowell. He testified 
also to the respectability of Dr. I. 






135 

Appendix E. 

Concluding Address of the Attorney for the Defendant. 

Let not a judgment against the defendant be thought light. The 
end of this action is to annihilate the character and usefulness of the 
defendant ; and such, undoubtedly, Dr. I. feels the attack with a 
sensibility proportionate to the injury aimed. His standing and 
reputation, therefore, form a trust, which he feels it a duty to defend 
for the benefit of the rising and thriving community, which comprises 
his present sphere of practice ; and also as the principal means he 
has, in connexion with the little prospect of fortune it affords, under 
Providence, of executing the humble scheme of happiness and im- 
provement he has in contemplation for himself, for his family, and 
society. Of all this the verdict outrageously sought by the plaintiff 
would simply rob him for ever. The consequences extend therefore 
to the community, which is hardly less interested in the result ; and 
what is the consequence of a limb like Lowell's, supposing he should 
never perfectly recover it, compared with the usefulness of such a 
physician as Dr. I. entirely lost to the present scene of his prac- 
tice ? Is there a member of the profession in this section of the 
country, that any indivividual who has witnessed the full expositioa 
of this case, in case of any accident happening to himself upon this 
spot, requiring the aid of a surgeon, would select in preference 
to this defendant ? And is there any portion of the state, that would 
not rejoice to receive the benefit of his skill, if it should be expelled 
from the county of Washington ? Rise, then, above the influence of 
prejudice, and restore him to a society, which is capable of appre- 
ciating his expertness and fidelity ; and inspire him with a due con- 
fidence in the justice of his fellow citizens to protect him against 
such an unprovoked and unfounded assault upon his rights, his feel- 
ings, and his practice. Sustain him against this fiery trial of his 
patience, and bring him out of the furnace without allowing a hair 
of his head to be harmed. A verdict against him would be his ruin. 
Call a soldier a coward, a clergyman a hypocrite — and judge what it 
is for a physician to be branded as a quack. Compared with his 
character, a treasure so deservedly endeared to him by the unrigh- 
teous manner in which it has been assailed, he values not his property 
a feather. If the jury arrive at the question of damages, he does 
not request them to trouble themselves about fractions. He does 
not entreat your mercy ; he makes no claim for commisseration ; 
and will not thank you for forbearance. By his express instructions 
his counsel are not only warranted, but required to urge upon you 
not to compromise his character by a verdict for mere nominal dam- 
ages. If you are obliged by your oaths to find a verdict for the 
plaintiff, he does not ask of you to stint them. Give him the whole 



136 

length of the lash — Give to the plaintiff, in that case, his just meas- 
ure, heaping full, and running over. Take from the defendant, if 
you please, the pittance of his humane and patient industry ; and 
take with it all further incentive to emulation and exertion; blast 
that reputation, which is the fair growth of a brief and honorable 
practice ; steep him in poverty to the very lips ; let him exhaust the 
cup you shall mingle for him to the very dregs ; bring down upon 
him the whole weight of the Harvard Medical Faculty, piled upon 
the Massachusetts General Hospital ; let the Chaldaeans come upon 
him, and the Sabseans make three bands ; and the wind from the 
wilderness smite upon the four corners of his house, until he shall 
be reduced to sit down among the ashes and scrape himself with a 
potsherd — nothing can deprive him of the consciousness of integrity, 
derived from the consolation of having performed his duty. 



Appendix F. 

The feelings experienced by the unfortunate Plaintiff, and the views he enter- 
tained, are expressed in the following conclusion of his Pamphlet. 

The amount of this interesting subject, appears to be this : viz. 
That I, in the prime of life, with a simple dislocation of the hip, fell 
into the hands of Doctor I. and Doctor K. by whose ignorance and 
negligence, I have lost the use of my hip for life ; that after suf- 
fering five excruciating operations, and expending about 1000 dol- 
lars in doctors' bills, nurses' bills, &c, and with a total loss of two 
years' time, and 1000 dollars more in an appeal to my ceuntry 
for redress ; 1 have lost a just and plain cause, and that too, by the 
improper management of the Court, and the corrupt influence of a 
combination of unprincipled men, from various parts of the county 
of Washington. 

I have now told my plain and unvarnished tale of woe, and when 
my readers arrive at this point, I trust they will be prepared to say, 
that I have unfolded to them a scene of injustice and oppression, 
which has few examples in the history of this country, and such as 
ought not to be passed over in silence by the government and people 
of this independent state. This cause is of no common interest to 
society, or the parties engaged ; for every good citizen must feel a 
deep interest in arresting the progress of imposture and quackery. It 
is one of peculiar bearing on the vital interests of many, for it strikes 
at the very root of fraud and deception in every profession ; and 
although I am a ruined man, and life has few charms remaining for 
me ; although I have been extremely unfortunate in the unexpected 
result of this suit ; there are no two acts of my life, on which I can 
reflect with more heart-felt approbation, than the prosecution of I. 



137 

and K., and the publication of this pamphlet ; and through subse- 
quent life. I shall look back with the proud satisfaction of having 
been a public benefactor, in exposing these Doctors and the Judge's 
charge to the world. 

Although I am satisfied, that this work is founded on the immuta- 
ble basis of truth and justice ; and that it is couched in decorous and 
appropriate, though strong terms ; yet I have no doubt it will be 
assailed by some one of the numerous host of quacks, pettyfoggers, 
and gamblers, with whose base influence I have had to contend 
during this protracted litigation ; but unless they do it in an ingenu- 
ous manner, and in their own proper names, I shall treat them with 
that silent contempt, which such communications deserve. 

# # # # ###### 

Although the loss of my property, and the treatment I have re- 
ceived, the loss of the use of my hip, and the pains and sufferings 
which I am doomed to endure through the round of time ; the recol- 
lection of past enjoyments, together with other misfortunes (not inter- 
esting to the public) do at times all rush upon my mind with a weight 
and impetuosity, beyond the power of human efforts alone to sustain. 
Yet, amidst all these calamities; amidst the clouds of darkness and 
doubt, injustice and oppression, I can look forward and see the 
glimmerings of the sun, which seem to indicate the approach of bet- 
ter days. There I can behold the most profound and consummate 
wisdom, guiding the destinies of men ; and I feel a consciousness, 
that the Divine blessing on the purity of intention, and the energy 
and perseverance which have characterized my hitherto rapid, but 
"unsuccessful career in life, will yet support and conduct me through 
the labyrinth of life's thorny maze, to the peaceful shores of eternal 
"blessedness, " where the wicked cease from troubling, and where the 
weary are for ever at rest." 

CHARLES LOWELL.* 

Machias, January, 1, 1825. 



* Since the greater part of these sheets were printed, I have seen Mr. Lowell, 
the plaintiff, for the first time, since I gave the deposition. His anticipations of 
evil had, I found, been realized to their full extent. His health had been 
gradually impaired by the change of habits produced by his lameness, and his 
spirits broken by repeated misfortune. 

To those who feel an interest, as I have no doubt many persons will, for this 
unfortunate man, it may seem that I ought to have defended his cause, and 
shown the real character of the treatment he had received. This, however, 
could not be done without exhibiting the conduct of others in an unfavourable 
light ; and I have been desirous to avoid this, any further than was called for by 
self- defence. 



18 



138 



Appendix Z. 

Some of those who are not fully acquainted with the nature and 
extent of the attacks made on me, will, I am aware, be disposed to 
question the expediency of bestowing the attention to the subject, I 
have done ; and perhaps they may also justly doubt the propriety of 
involving, in this discussion, the opinions of respectable gentlemen, 
in and out of the medical profession, though I have omitted their 
names ; and notwithstanding the reasons assigned in the beginning 
of this pamphlet. 

For the satisfaction of those who may not have seen, in the at- 
tacks of the defendants' attorney, sufficient reason to justify the 
course I have taken, i will make an extract or two from a series of 
publications which appeared in newspapers printed at Eastport, the 
town where the defendant lives. Whether they were written in any 
part by the defendant, I know not. They are published in the place 
where he resides, and it is obvious that some of the facts must have 
been derived from himself. 

This series is begun, by republishing a review from the Boston 
Medical Intelligencer, which these writers think proper to attribute 
to me or my friends, because it contains some complimentary re- 
marks, although it has also opinions diametrically opposite to those 
expressed by me, and in every feature bears a character which dis- 
tistinctly marks it as not emanating from me. Of the succeeding 
numbers, the following may serve as specimens. 



Extracts from the Eastport Centinel of December 10, 1825.* 

" Mr. Folsom, 

" A correspondent of your paper, a short time since, made some 
remarks on an article in the " Boston Medical Intelligencer," pur- 
porting to be a Review of the Trial of Lowell vs. Doctors I. and K. 
which has made no little stir in the medical world, and, before it is 



* These productions were, it should seem, printed for a more extensive dis- 
tribution, than the ordinary circulation of the paper. Many copies were sent 
me, mostly by anonymous friends, and a considerable part of them I found to 
be printed with one blank side of the newspaper, additional copies of this series 
being struck off for a more enlarged diffusion of their contents, and, as I have 
since learned, distributed by the defendant. I might add, that I have received 
from Maine, through the post-office, anonymous writings of an abusive character, 
probably the production of medical students, who had been deceived as to my 
opinions and dispositions, by the pamphlet of the attorney, and the newspaper 
publications. They afford additional proof of the disadvantages resulting from 
publications of the description of the report of this trial ; since its allusions 
and insinuations seem to encourage and support those, who are ready to im- 
prove any opportunity to attack the reputation of others. 



139 

suffered to remain in quiet, I am rather apprehensive will make still 
more. 

" By publishing the following remarks, with the extract from the 
<( Review,' 7 you will confer on me and others a particular favor. 

" Dr. I. will not contend with Dr. Warren that it is impossible the 
head of Lowell's os. femoris is in the axilla, but to him it is unac- 
countable that any man of the least pretensions to anatomical know- 
ledge should think it in the ischiatic notch. 

" When Dr. I. was first called to Lowell, his injured limb stood 
off from the other at an angle of about 40 degrees ; a tumor was 
seen, and the head of the femur was felt by Dr. I. over the foramen 
ovale, the trochanter major of course displaced. When Dr. I. left 
him, the direction of the whole limb was natural, its motion (see 
Coffin's deposition) free, its length corresponding with the other, 
and the trochanter major to be felt in its natural position. Dr. I. 
judged Lowell's case to be, when he was called to him, a dislocation 
into the foramen ovale, accompanied with a fracture of the acetabu- 
lum, and after he had operated upon him, that he had reduced it. 
Dr. Warren saw Lowell some months afterwards, and judged that it 
was originally a dislocation into the ischiatic notch, and that it never 
had been reduced. His cogent reasons for his belief are to be found 
in his depositions published in the Report of the Trial. 

" A correspondent of the Boston Patriot complains most bitterly of 
the medical aristocracy now existing, and says, ' a reform is most 
devoutly desired.' I think, if it was not wished for by a liberal 
minded individual, that the public good demands it in a most pe- 
remptory manner. ' The truth, and the whole truth ought to come 
out.' On the one hand, if Dr. I. is not fully competent to discharge 
the duties which belong only to the accomplished physician and 
surgeon, it ought to be fully developed, as he is believed, by those 
who are the best acquainted with him, to possess a high degree of 
excellence as a medical man, and let them be no longer deceived. 
On the other hand, if J. C. Warren should be found not worthy of 
the high degree of confidence that has been placed in him, in conse- 
quence of the nakedness of his mind, I think that he must take a 
high rank among that detestable class of men who pretend to much, 
and know but little. If Lowell's case was a plain one, a case not to 
be mistaken by medical men of high standing, and if medical books 
are so clear and explicit on the subject, that the way-faring man 
could not err therein ; and if no medical authority extant intimates 
that the knee and limb of one side being thrown off from the other 
in an awkward and unnatural manner, is an indication that the head 
of the thigh bone thus thrown off is lodged in the ischiatic notch ; 
and if no man of common sense ever dreamt of the impossibility, I 
do think the prospects of invalids, when they become inmates of the 
Massachusetts General Hospital, to be the most deplorable of any 
situation that 1 can imagine." 

{i The circumstance of their volunteering their depositions, as they 
certainly did, to Lowell ; for every man knows that they were not 



140 

compelled by law to do it, as they lived out of the State in which 
the action was brought ; and the tenor of their depositions, as it 
must appear to every dispassionate reader, throws the lie in the 
reviewer's face. It would seem, that they believed a verdict in 
Lowell's favor (regardless of equity towards the defendants), would 
prove that they did not see through glasses darkly ; would prove, in 
fact, an impossibility, and thereby save their reputation.' 

Such are the remarks which the defendant or his friends, have felt 
justified in publishing. What I have quoted is by no means the most 
abusive part of their productions ; but there being no great choice, 
T have taken the above at a venture, as a specimen of the rest. 

That the defendant should have felt some irritation at the incon- 
venience he had experienced in consequence of the opinion formed 
by me, is perfectly natural. But a moderate degree of good feeling 
would have led him to restrain such publications, when he well knew 
from the tenor of my letter, from the four cross interrogatories, 15, 
16, 17? 18, as well as from various concomitant circumstances, that 
I had every disposition to prevent his suffering, and that nothing 
would have led me, knowingly, to say what might be employed 
against him, but obedience to the laws of the country. 

The writer of the paragraph, quoted last, boldly asserts, that we 
volunteered our depositions, and that we were not compelled to give 
them by law, because we lived in a different state. A person who 
undertakes to assail the character of others, with so little reserve as 
he has done, ought to have more knowledge of the facts of which he 
speaks. It is well known, that citizens of the United States are 
compelled to give testimony in causes between citizens of different 
states ; or become liable for all damages. How else could justice 
be administered in the national courts ? 

So far from volunteering my testimony, I positively refused it, till 
I found the law of the land could compel me to give it ; and then, 
as I have more than once repeated, I gave it most reluctantly. 

There is but one other part of this incongruous mass of assertion 

and insinuation, which I shall notice. " When Dr. " say these 

newspaper writers, " was first called to Lowell, his injured limb 
stood off from the other at about an angle of 40 degrees," &c. 

From this and what follows it appears, that the defendant has 
abandoned the cause of the deponent A, who says, " that from the 
nature of the injury described to me by Lowell, it could hardly 
be possible that the hip should be dislocated. A fall on the back, 
with the weight of the horse upon it, would be likely to break tha 
bones of the pelvis, and might drive the head of the bone through 
the bottom of the socket, but could not dislocate the joint." (See 
deposition A.) 

When it is considered, that but for the difference of opinion from 
us, expressed by the deponent A, the defendant would probably have 
lost his cause, it appears very ungrateful in him to abandon, and even 
to attack, or allow to be attacked, the opinion, and thus indirectly 
the character of so important an auxiliary. 



141 

Further, in regard to the conduct of the deponent in the sur- 
gical management of the case, which is spoken of in these news- 
papers, I have aiways wished to avoid giving any opinion. I 
therefore never charged him with any malpractice; or with a want 
of as much knowledge, as should be reasonably claimed for him ; 
nor do I now. I wish only to defend my own ground. But in the 
first part of the production quoted, the writer has contrived to con- 
nect the opinion of the defendant with mine in such a manner, as 
calls for some remark. After informing us, that the defendant con- 
sidered the case of Lowell as a dislocation in the foramen ovale 
before he reduced it, he has made me to say, that it was originally a 
dislocation in the ischiatic notch. This is not the fact. I expressly 
declined giving an opinion, as to what took place at the period of 
the accident, and spoke only of what I saw at the time I examined 
the patient. There is not the least intimation of its having been 
originally an ischiatic dislocation. 

The writer of this statement, which, as I have said, is repeated 
elsewhere in his productions, appears by no means to have improved 
the position of the defendant. It seems, from his story, that before 
any effort was made at reduction, the defendant was perfectly aware 
of the existence, and the character of this accident. The limb, he 
says, stood off at an angle of 40 degrees. 

Attempts were made to reduce it, according to the deposition of 
Coffin, which is introduced by this writer as favorable to the defend- 
ant, and which, for this reason, I have reprinted. The direction of 
the limb, after these attempts, was changed, and " both legs were of 
a length, so far as I saw, and the limb was more easily moved."* 

Yet the same Coffin informs us that he was present at a period 
from twelve to fourteen days after the injury, when, the defendant 
being there, " Lowell asked the reason of the hollow at the outside 
of the hip, and expressed his fears that the bone was out of place." 
Nothing was done with a view to replace it. In about two and a 
half months after, he was examined by me, and the bone was found 
dislocated ; the existence of which, I suppose, to be shown by a 
stronger body of evidence than any adduced by this newspaper writer 
in support of what he has advanced. Considering, then, the condi- 
tion in which the limb now is, together with the statement made by 
him, does not this author involve the person he defends among the 
following alternatives ? 

First, that by the attempt made for reduction, the bone was 
actually reduced; yet, when it afterwards got out of place in a Jit, 
or in some other strange way, the defendant, though seeing the 
disordered state of the limb, made no attempt to restore it to its 
place. 

* Writers on dislocation state, that, immediately after the accident, and es- 
pecially after attempts made to reduce it, the limb appears more flexible than 
might be expected, or than it is ever after. This fact should be a caution to 
young practitioners, not to be satisfied too easily with having effected the re- 
placement. 



142 

Secondly. Or that when the reduction was attempted, the head 
of the bone was not moved from the situation in the foramen ovale, 
where, it is said, he found it. 

Thirdly. Or that at the time of the grating and change of direc- 
tion of the limb, the head of the bone was slipped from the foramen 
ovale to the ischiatic notch, or os ischium. 

I wish not to be understood as bringing either of these charges ; but 
to leave the matter to the decision of the newspaper writers between 
themselves ; and, in settling the question, they must take particularly 
into view what Sir Astley Cooper has said on the third case. " Al- 
though a dislocation in the foramen ovale may be occasionally re- 
duced by attempts made in a very inappropriate direction, yet the 
following case will show the mischief which may occasionally arise 
from an error in this respect. I once saw the following instance. A 
boy, sixteen years old, had a dislocation of the thigh into the foramen 
ovale ; he was placed upon his sound side, and an extension of the 
superior part of the thigh was made perpendicularly. The surgeon 
then pressed down the knee, but the thigh being at that moment 
advanced, the head of the bone was thrown backward, and passed 
into the ischiatic notch, from which situation it could not afterwards 
be reduced." 



PL I. 




PI. II 




PI. III. 







PI. V. 




PI. IV. 




After a few copies of Dr. Warren's Letter to 
Judge Parker had been sold, Mr. Lowell, the 
Plaintiff called on the publisher to say, that having 
seen the publication, he did not consider his case 
fairly represented ; as the Deposition first given 
by Josiah Coffin was not printed in the work, but 
one given by said Coffin twenty-six months after 
which varies in a very essential manner ; and as 
an act of justice to Mr. Lowell, Dr. Warren has 
consented to have this printed and annexed to the 
work. 



JOSIAH COFFIN'S FIRST DEPOSITION. 

I Josiah Coffin, do give evidence, testify and declare, 
That being at Lubec, in September 1821, was at work on a 
House of Jabez Mowry, near the road, saw Mr. Charles Low- 
ell when he fell from a Horse and was much wounded by the 
horse falling upon him ; that I helped carry him to his house, 
and was present when Dr. K. came in, heard Mr. Low- 
ell request some person to call Dr. K. before we had got 
him to his house. Mr. Lowell was placed on the bed and Dr. 
R. said that his Hip was out or dislocated. Dr. K. said 
that he thought that he could set it, or that there would 
be no difficulty in setting it, but that it would be a hard job 
for him to bear. Dr. K. then commenced the operation 
by placing Mr. Lowell on his back, and called upon several 
men that were present to assist him ; and after operating a 
short time, perhaps fifteen minutes, then said that the joint ivas 
in and called upon several present to take hold of his leg, and 
see that if they did not think it was in, and they generally, or 
all, expressed their opinion that they thought the bone was in, 
but I thought not, myself; and at the door told Mr. Lowell's 
brother, that I thought that the bone was not in, any more 
than when he was carried into the house, and recommended 



the sending for Dr. I. and Mr. Lowell's brother and Mr. 
Stearns both expressed a wish that I should express my opin- 
ion before Mr. Lowell and Dr. K. and all present, and 
which I did, and Dr. K. again asked me to examine the 
leg, and said it must be in its place (or something like that,) 
and I did, and expressed my opinion from the position of 
the leg that the bone could not be in its place, the leg stand- 
ing out in an unnatural position from the body, and could 
not be moved inward, without appearing to give him very 
great pain, but was moved outward, without appearing to in- 
crease the pain. That there was no purchase used for the 
extension of the limb, but several men with their hands, and 
the Dr. placed a ball of cloth between the legs of the patient. 
When the Dr. first said the leg was set, I had not heard any 
snapping or grating of the bones. I do not recollect whether 
Dr. K. bled the patient, either before or after the opera- 
tion. I should think in about two hours or a little more, Dr. 
I. came over and I went with him to Mr. Lowell's, — the 
patient appeared to be in considerable pain, Dr. I. pro- 
ceeded to examine Mr. Lowell's hip and shook his head; he 
stopped a spell and walked across the room, asked Dr. R. 
to take hold of the limb and he would be convinced. — 
Dr. K. then said I did think that the bone was set, but 
now think that I had been mistaken. Dr. I. asked Dr. 
K. to go into the other room, and they did go ; after they 
came in, Dr. I. said Mr. Lowell we must hurt you again, 
as what has been done has done no good, (or words to that 
effect.) Mr. Lowell answered, that you must do what you 
think right, and I must bear it. Dr. I. said that he thought 
the socket of the hip bone was fractured. The Dr. then re- 
quested the bye-standers to leave the room ; after some time 
Mr. Lowell's brother asked me to go in, that more help was 
wanted, that I went in, a large cloth was placed round the 
patient's leg above the knee, and one or two men had hold of 
the cloth and I was asked to take hold of the leg below 
the knee : that a sheet was passed between the legs and 
over the shoulder of the well side, with men hold of the 
sheet at the shoulder, and Dr. /. took hold of the Hip 
and thigh, and asked us to pull and extend the leg which we 
did — after which Dr. I. took hold of the leg and moved it 
in different directions, ashed Mr. Lowell if it did not feel na- 
tural to what it had done, and Mr* Lowell said that it did. Dr. 
I. and Dr. K. then both said that the hip was well set, or set 
correctly — (before I left Mr. Lowell's, I heard Mr. Lowell say 
something to Dr. I. respecting coming over, that Mr. Lowell said 
he did not value the expense, and I think Dr. I. said that I icill 
come over tomorrow.) — that Dr. K. was handy and could be in 
every hour, or something to that effect, and asked Dr. R. if he 



had certain medicine. At this operation by Dr. I. and Dr. K. 
there was no ball of cloth or fulcrum placed between the legs. 
Something like a fortnight after, 1 was to see Mr. Lowell with 
Dr. I. Mr. Lowell told Dr. I. that he had been in extreme pain, 
and that he feared that the bone was not in its place. (Mr. Low- 
ell said that he had a struggle by pain, and did not know but 
that might have been the cause of getting it out, if it had 
been in, and was confident that it was not in its place, that 
Dr. I. replied that the bone's being fractured would cause pain, 
and that it toould be sometime before he would be free from pain ; 
but that the bone was in its place, and that there was no doubt 
but that he would be as well as ever again.) Mr. Lowell then 
shew Dr. I. that there was a holloio place at the out side of the 
hip joint. The Dr. replied, that when he had gathered strength 
so as to bear the weight of his body, that the hollow place would 
fill up. Mr. Lowell stood up at the Doctor's request, and sup- 
ported himself by my shoulder and the bed-post. The Dr. then 
took hold of his leg and swung it and said that he did not see 
any thing out of the way, but that it was correct. And further 
the deponent saith not. JOSIAH COFFIN. 

Opened and filed in Court, Sept term, 1822. 

J. HARRIS, Chile. 

Washington, ss. 

On the twenty-seventh day of March, in the year of our 
Lord one thousand eight hundred and twenty-two, the afore- 
said deponent was examined, and cautioned, and sworn, 
agreeable to law, to the deposition aforesaid, by him subscri- 
bed, taken at the request of Charles Lowell, of Lubec, in 
the County aforesaid, Trader, and to be used in an action of 
trespass on the case now pending between him and K. 
of Lubec, aforesaid, Physician, and I. of Eastport, in said 
County, Physician,before the Circuit Court of Common Pleas, 
next to be holden at Machias, in said County, on the first 
Tuesday of September next, and the adverse party was not 
present, Dr. K. was notified. The said Deponent living 
more than thirty miles from the place of trial, is the cause 
of taking this deposition. 

DANIEL PEASE, Justice of the Peace. 



H, 



LETTER 



TO THE 

HON. ISAAC PARKER, 

CHIEF JUSTICE OF THE SUPREME COURT OF THE STATE OF 
MASSACHUSETTS, 

CONTAINING REMARKS 




DISLOCATION OF THE HIP JOINT, 

OCCASIOHED 

BY THE PUBLICATION OF A TRIAL 

WHICH 

TOOK PLACE AT MACHIAS, IN THE STATE OF MAINE, JUNE, 1824. 



BY JOHN C. WARREN, M. D. 

PROFESSOR OF ANATOMY AND SURGERY IN HARVARD UNIVERSITY, AND ACTING 
SURGEON IN THE MASSACHUSETTS GENERAL HOSPITAL. 



WITH AN APPENDIX 

OF 

DOCUMENTS FROM THE TRIAL NECESSARY TO ILLUSTRATE 

THE 

HISTORY OF THUG CASE. 



CAMBRIDGE : 
PRINTED BY HLLLIARD AND METCALF. 




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